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later experiences of chloroform, and the single anterior flap.The chief advantages of this method are the following:-first,that as in the case of Mr. Erichsen just cited, or in Mr. CharlesGuthrie’s patient, the artery is grasped by the assistant withthe flap even before the vessel is divided; the operation isquickly done; the flap when cut anteriorly falls by its ownweight into its place; purulent collections escape more readily;and, lastly, the wound consists of one continuous surface-not,as in other operations, the apposition of incongruous parts,like the external and internal muscles dragging different ways.The chief danger to be apprehended in amputation of the hipis excessive hæmorrhage, the incision being so high up that nois excessive haemorrhage, the incision being so high up that notourniquet can be applied, and no pressure of the artery at thegroin trusted to. Some even of our oldest surgeons-amongstwhom we may mention Mr. Lawrence and Mr. Stanley-never saw the operation before the present opportunity; weare, therefore, the more particular in describing it. The largeanterior flap is formed by transfixion, the patient’s body beingbrought well forwards on the edge of the table, so that the natesproject, while the sound limb is secured by an assistant. Theknife must be fourteen or sixteen inches long, and enter onthe left side, two fingers’ breadth below the anterior superiorspine of the ilium, and carried deeply in the limb behind thevessels, and across the joint, its point issuing immediatelyabove the tuberosity of the ischium. The limb, which duringthis stage of the operation was slightly flexed on the abdomen,was now forcibly abducted and everted when Mr. Tatumopened the capsule, the head of the femur at this point, if it bepushed up, starts out at the acetabulum; the remainder of thecapsule is then cut, and the posterior flap made by carryingthe knife downwards and backwards. If the operation is per-formed on the right side, the anterior flap is of course formedby the insertion of the knife in a reverse direction above thetuberosity of the ischium. A good deal depends on the assistant,as we have said, slipping his finger under the anterior flap asit is being formed, and compressing the femoral. No bloodwas lost from the artery.The operation in this case was performed on the 5th of the

present month (July). The after treatment has not presentedany peculiarity. The patient has had wine, beef tea, and

opiates; and, except that he feels the " twitches of his toes,"as he calls it-of a limb that has been in the museum threeweeks-the poor fellow seems to be quite well.

GUY’S HOSPITAL.

RESECTION OF THE KNEE-JOINT, FOLLOWED BY HOSPITAL

GANGRENE; AMPUTATION.

(Under the care of Mr. BIRKETT.)A CASE of excision of the knee-joint, followed by amputation,

at present under Mr. Birkett, (W. B-, aged thirty-four,) isof considerable importance, as bearing on more than one pointof surgical practice-namely, the relative severity of amputa-tion above the knee, when compared to resection of that articu-lation itself, for incurable disease of the cartilages and synovialmembrane, and the dangers attending hospital gangrene insuch cases. Amputation of the thigh, amongst some few sur-geons, is considered a much more serious operation than re-section of the knee; while others, from different data, lookupon resection as the more severe operation of the two.Statistics at present are necessarily limited, as excision and re-section of joints have only been introduced really into practicewithin the last few years. Hospital cases of excision, in otherwords, of one or two hospitals, and statistics of amputations ofall favourable and unfavourable kinds, have been got togetherfrom various sources, to show, for instance, that in comparingthe rate of mortality from hundreds of amputations, with therelative per-centage of deaths from excision, the latter opera-tion is more frequently followed by recovery and permanentadvantage to patients. Resection of the knee is perhaps anexceptional case to other resections, as the white swellings andother formidable affections of this articulation are almost ex-ceptions to the immunity of other joints from such diseases.Mr. Hilton, at Guy’s, as the result of many "knee cases,"believes that counter-irritation is not used enough in suchdiseases. Sir B. Brodie also advocates counter-irritation, andsteady application of small numbers of leeches. We observethese views very generally acted upon by Mr. Skey and Mr.Lloyd at St. Bartholomew’s, Mr. Solly at St. Thomas’s, Mr.Erichsen, and Mr. Hancock. Some other surgeons trust moreto constitutional treatment, rest in hospital, cod-liver oil,stimulants, such as good food, porter, wine, sea air, &c.; yetif the synovial membrane or cartilages be once seriously engaged,

and pulpy thickening ensue, we have ne resource but resec-tion.

In thirty-three cases of resection of the knee, in Englandand Dublin, the rate of mortality was less than that followingamputations of the thigh, and yet we are told that almost allthe patients operated on for resection of the knee, in France,by Roux, Moreau, and some others, died. Nor has this opera-tion been much more fortunate in the hands of Syme, Crampton,or Jseger, the last-named surgeon having had ten deaths inthirteen cases. These results, in fact, have led to the disuseof this operation, and to very great controversy as to its value.A very obvious source of error, however, has been in comparingtwo matters quite distinct-deaths from incurable or malignantdisease of the knee, where i1fis well known anchylosis, or evenosseous junction of an ordinary fracture, seldom takes place,with amputation in healthy, robust subjects, for accident.In the present instance, and after fully considering all the

points, Mr. Birkett decided on resection of the knee-joint,which he performed on the 29th of May. The history of thecase did not present anything unusual. The knee had beenbad for two years and a half; was swollen and painful; butthe man had received no injury. A semilunar incisionwas made through the ligamentum patellae, round the lowerpart of that bone, the knee being flexed, as in the operationrecommended by Syme; the vessels at the back of the jointwere carefully avoided, and the parts at the sides, with thelateral and crucial ligaments, incised just sufficiently to allowroom for the saw. There was nothing particular in the detailsof the operation. Mr. Birkett, in order to prevent that greatdeformity of the anchylosed limb when cured, so often observed,by which the upper limb seems to "ride over" the lower, thelatter dragged, perhaps, by the muscles inserted into theposterior part of the tibia and fibula, carried the saw, we

thought, in the lower section of the cup-8haped cavity of thehead of the tibia, in a somewhat similar direction, not quitestraight, as in ordinary amputations, while the line of incisionof the upper or femoral aspect of the articulation was alsocarried as in natural apposition of the parts, and made convex,the bony surfaces fitting well together. These, we have reasonto know, were in beautiful apposition afterwards, when Mr.Birkett was obliged to amputate.

Mr. Birkett operated early in this case, so as to give thepatient the chance of recovery by amputation, if the operationby resection did not succeed. The case went on very well forthree weeks or a month, till attacked about this period withhospital gangrene. Mr. Birkett, under the circumstances, andlooking away from the gloomy aspect of the case, placed thepatient at once under the usual plan of treatment for this newcomplication-charcoal and carrot poultices externally, withthe application of nitric acid, &c., with strict injunctions as tothe use of sponges, &c., in addition to the exhibition internallyof morphia at night, with bark and chlorate of potash. The dietconsisted of beef-tea, porter, wine, &c., as extras, joined to theusual full diet. We said, looking away from the gloomy aspectof the case, as in all probability, Mr. Birkett said to his class,hospital gangrene would save the patient from pyaemia as hehad never seen both together, and had rarely or never seenpatients sink at Guy’s from one, while they almost as rarelyor never escaped death when attacked with the other ; in fact,hospital gangrene had been recommended as a cure for cancer.The patient, however, some days after, was obviously sink-

ing : and here the erroneousness of mere statistics, taken bythemselves, was forcibly shown; for if amputation be a moresevere operation than excision or resection, it would be, to usea popular phrase, adding fuel to fire now to amputate, or atleast to double the danger to expose the man to a second opera-tion. Of two evils, guided, at least, by the mathematicalschool of medicine, one would prefer, Mr. Birkett observed,the minor one of leaving things as they were than opening upa new wound, and giving the system, staggering, as it were,under the effects of the first shock, a second shock, (alwaysaccording to statistics, the reader will remember,) from whichshock the patient could not recover.Mr. Birkett, however, in consultation and agreement with his

colleagues, decided on amputation, on July 6th, subsequent towhich the change in the patient’s condition for the better hasbeen most marked and unequivocal. An extensive double woundof bones and integuments, sloughing and gangrenous, some-thing like what we have more than once seen in resection ofthe elbow by Mr. Fergusson, has been removed, and the manno worse than if amputation had been originally performed.To this case of excision of the knee-joint, we may add a case

by Mr. Holt, in the Westminster Hospital, where there is nowperfect anchylosis of the knee-joint; a case of excision of the

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radius by Mr. Erichsen, quite well; Mr. Stanley’s case ofexcision of the wrist, (with the tendons cut with the flap,)doing very well; a case of excision of the shoulder-joint thisweek, by Mr. Birkett, also doing well.

KING’S COLLEGE HOSPITAL.

ERYSIPELAS AND PYÆMIA IN RELATION TO SURGICAL ACCIDENTS,TREATED BY WINE, AMMONIA, AND OTHER STIMULANTS.

(Under the care of Dr. TODD.)The prophylaxis or due prevention of purulent infection, in

surgical cases in hospitals, must ever be a subject of paramountinterest to the practising surgeon. Pyaemia holds a very pro-minent place in the causes of death in the majority of thoseoperated on in hospitals. An opinion, however, has gainedground, perhaps too readily, of the total incurableness of thisaffection, and patients have been too often abandoned to their fateunder this impression. The rule usually adopted amongst sur-geons is, to prevent as much as possible the formation of pus, or,where pus is already formed, to assist and encourage its exit byfree incisions and pressure over purulent sinuses. We havebeen very much gratified, however, of late, with the result ofsome cases allied to pyaemia, under the care of Dr. Todd, inthe medical wards of King’s College Hospital. Dr. Todd pro-poses to check pyaemia by diminishing excess of inflammationin wounds, and checking erysipelas, both of which, as leadingto the secondary results of inflammation, help to induce pysemiofever. Pyaemia amongst the wounded soldiers, in summer, inthe Crimea, for instance, is not less fatal than scorbutus in thewinter, but both are curable, according to Dr. Todd, if onlytreated by stimulants from the first, such as brandy, beef-tea,ammonia, opium, &c. It would seem, that while surgeonshave been in too many cases looking on pyeamia as theoreticallyquite incurable, it has often cured itself; and while we havebeen hitherto absorbed in the microscopical question of whetherpus-globules enter the circulation in this disease as such or arebroken up into poisonous matter, the more practical men haverecognised phlebitis as at once an almost constant cause ofpyaemia, and a not unfrequent mode of cure also of the pysemiccomplication, set up by Nature itself. The cause of pyaemia,we may say, as when not suspected, the mixture of the ele-ments of pus in phlebitis, if not pus itself, may exist along theveins, even as far back as the auricles of the heart. This phle-bitis, if properly treated, leads to a blocking up of the vein byfibrinous adhesion and a stoppage of the purulent absorption,thus becoming a means of cure ; but if neglected or encouragedby depressing and antiphlogistic remedies, only leading to themost disastrous results-further formation of pus, with hecticand irritative fever, general debility of the system, unfavour-able to the dispersion or resolution of the fever, or poison in thesystem, and death.One of Dr. Todd’s cases, a type of a class of cases received

into this and other hospitals, was the following :J. C-, aged about twenty, admitted into King’s College

’Hospital with bad erysipelas of the face and head. The casewas one of those very severe attacks in which the man mightdie, and the erysipelas might be said to have attacked thebrain. Dr. Todd, however, believes that erysipelas does not" fly to the brain," but that, as in the puerperal peritonitis ofwomen, which he considers as an erysipelatous affection ; asin oedema of the glottis, and as in pysemia, both so fatal-the’cause of death is to be found too often in the secondary resultsof inflammation of an erysipelatous kind, and fever. Ery-sipelas has a tendency to attack the areolar cellular tissueof organs, but this, according to Dr. Todd, is altogetherobviated by treating such cases from the beginning withbeef-tea and ammonia, and bark, and not, as formerly, byleeches, bleeding, and mercurial purgatives. Erysipelas maythus be cut short, and get well in seven days, instead of

being eighteen or twenty. We have observed in all the hos-pitals, of late, these views coming more and more into use.Some of the very old practitioners still adhere to water-gruel,purgatives, depletion, aad antiphlogistics ; while, as a moregeneral result, the opposite plan, which we owe so much to theadvocacy of Mr. Skey, Mr. Prescott Hewett, Mr. Hilton, Dr.Todd, Mr. Wakley, &c., leads to a more scientific treatment ofcases and to the saving of human life. The latter surgeon isnow treating a severe case of erysipelas at the Royal FreeHospital with nutritious food and stimulating medicine. The

improvement has been very marked.Pyaemia is sometimes checked by stopping the inflammation

of the veins by the free application of caustic, or, as more re-

cently advised and practised, by that of the actual cauteryitself along the course of the vein, to encourage adhesive in-flammation. The experiments of Cruveilhier, in which mer-cury was injected into the veins, and almost simulated thephenomena of some of the secondary results of inflammationand pyeamia, all further corroborate Dr. Todd’s opinions.Lebert, it is true, demonstrates that pus in the blood destroysthe globules of the blood itself, diminishing its fibrin, andprecipitating its fatty matters; but not showing that this maynot lead to purulent deposits in the lungs and liver, ending indeath. These fatty deposits in the heart and bloodvessels ofthose dying of pyaemia we have seen in the dead-house; but allor many of such secondary results of inflammation attendingsurgical operations may be obviated, according to Dr. Todd,by joining a medical to a surgical treatment of such cases. Theremote causes of pysemia and erysipelas, according to the mosttruthful observers, being the crowding together of surgicalpatients and neglect of their wounds; the closing up too muchof wounds and stumps, as observed to us not long since by SirRobert Carswell; next, wounds of veins and ligatures of veins;but, above all, certain epidemic or meteorological influences,especially in large cities like Paris or London, which at specificseasons interfere with the healthy formation of blood and pus ;while the immediate or efficient pathological cause of pysemia,seems undoubtedly to be pus or its serum absorbed into theeurrent of the circulation. This the surgeons of the Frenchschool do not hesitate to prevent, and by amputation of a limb,to cut off the absorbing surface on the access of the first rigorsof the pyaemicfever; while Dr. Todd, on the other hand, wouldobviate it on the principle of " principiis obsta," anticipatingthe secondary evils of inflammation by cutting the latter shortby the treatment now found more effectual than that formerlyobserved.

Hospital Reports.NORTH STAFFORDSHIRE INFIRMARY.

A CASE OF SEVERELY CRUSHED ARM, WITH FRACTURE OF TWORIBS AND EMPHYSEMA; AMPUTATION AT THE SHOULDER-JOINT; RECOVERY.

(Under the care of Mr. SAMUEL MAYER TURNER. )

(Reported by ’Wx. HENRY FOLKER, L.A.C., HoTisc-Surgeou tothe Infirmary.)

JOSEPH C-, a short, strongly-built man, aged thirty-eight, was brought to the Infirmary between eleven and twelveo’clock on the night of the 16th of January last, in consequenceof a severe accident met with on the railway. It appears thatthe man, who was a smith at the Stoke railway station, whilstcrossing the line in a state of intoxication, was struck in theright side by the buffer of an engine, which knocked him down.He fell with his arm across the rail, and the engine and tenderpassed over it. A surgeon in the neighbourhood, who wassent for, bound up the arm so as to compress the bleedingvessels, and brought him at once to the Infirmary.On admission, his right arm was found to be literally smashed

from the elbow to within four inches of the head of thehumerus; two ribs on the same side were broken, and therewas emphysema; he was almost senseless from intoxication, alarge quantity of brandy having been given him at the stationin consequence of the loss of blood he sustained. Havingcarefully ascertained that no haemorrhage was going on, alittle wine and carbonate of ammonia was given. At aboutone o’clock the arm was removed at the shoulder-joint. The

operation at the joint was rendered necessary by the extensivelaceration of the soft parts, which were torn and totally dis-organized so high up as only to leave just sufficient to cover

the joint. The operation was commenced by an incision fromthe acromion process directly downwards for about fourinches; a posterior flap was then formed by transfixion. The

part on the anterior aspect of the arm being very irregularlytorn, a flap was formed by cutting from without inwards, butnot extending so far underneath as to include the artery.Disarticulation was easily effected, and the limb was then re-

moved by one sweep of the knife. Three vessels required. ligatures. The parts were then brought together by sutures! and supported by strips of plaster, and the whole covered! lightly with water-dressing and a bandage. Very little bloodwas lost during the operation, but it was necessary to administer

. brandy pretty freely, he was so extremely low. The patientwho was carefully watched during the night, was extremely