478

wound were carefully adjusted, and kept in position by meansof silk sutures and strips of plaster. The patient complainedof but little pain after the operation, and, having been keptcompletely under the influence of chloroform, of none duringits performance. She was kept for some few days on nourish-ing spoon diet. The upper part of the wound healed rapidlyby first intention; the remainder healthily, and without loss Iof substance, by granulations. The sutures were removed at I

intervals, beginning after the first forty-eight hours. Thevacancy within the mouth caused by the removal of so largea mass speedily began to fill up.

Dec. 8th.-She has had no bad symptom, and at the presentdate the wound has entirely and soundly healed. Consideringthe amount of structure removed, and the extent of incisionneedful for its removal, there is now but little disfigurement,and this too is rapidly subsiding. She swallows both solidsand fluids with perfect comfort; and the portion of palateremoved is replaced by a firm fibrous structure.On examining the part removed it was found to consist of

the left superior maxillary and palate bones, embedded, as itwere, in a substance in some parts gelatiniform, in others firmand elastic, indeed almost semi-cartilaginous. This structurefilled, and was adherent to the inner walls of, the antrum ;slightly bulged upwards the orbital plate of the bone; pro-truded through the inner wall, and nearly filled the nasalcavity of that side ; whilst the outer wall was transparentlythin. and also much bulged outwards.

ST. THOMAS’S HOSPITAL.CASES OF RESECTION OF THE KNEE-JOINT; CLINICAL

REMARKS.

(Under the care of Mr. LE GROS CLARK.)

THE record of unsuccessful operations is at least as im-

portant as that of such as have a favourable issue; and thisremark especially applies to the subject of resection of joints,on which there still exists great diversity of opinion amongstsurgeons. There are also special points of interest in the fol-lowing cases, which can scarcely fail to prove instructive.

CASE I.-A young woman, aged eighteen, of delicate aspect,was admitted into the hospital in March, 1863. She was of adecidedly strumous diathesis, though her general health hadpreviously been tolerably good, until she had what she de-scribed as an attack of rheumatism, which terminated in pain-ful swelling of the knee. Three months elapsed before shewas brought to the hospital; and after this she continuedunder treatment for four months, with just sufficient relief atintervals to encourage persistence, when the local disease andgeneral suffering rendered some operation necessary. Accord-ingly, excision of the diseased surfaces of the entire joint wasperformed, including that of the patella. There was extensivesubarticular caries, besides partial destruction of cartilage, andmuch purulent infiltration around the joint and in the pop-liteal space. She rallied very slowly from the operation, butwas so far recovered as to be sent to Margate in October of thesame year. On her return she was again admitted into thehospital, with several sinuses discharging ireely, but the lineof incision healed, and the opposed surfaces of bone so firmlyunited as to admit of free circumduction of the limb, with-out motion or pain at the knee-joint. Hope was still enter-tained that by care, good diet, and rest she might still makea good recovery; and, for a time, it was thought this hopewould be realized. Ultimately, however, it was apparent thatamputation was the only chance of saving life, and the opera-tion was performed in October. She suffered much from shock,as at the previous operation, and sank a few days afterwardsfrom the effects of secondary haemorrhage, fifteen months

having elapsed from the period when resection of the jointwas performed.

E.T:Clmination of the amp1äated limb.-The scar of the previousoperation of excision was seen on the surface, and there wereseveral sinuses on both sides of the joint. On dissecting 06the soft parts, the patella was found anchylosed to the femur,but with sinuses running beneath it. There was also tolerablyfirm bony anchylosis of the femur and tibia. A portion ojpale, necrosed bone was seen both on the inner and outelaspect of the joint, but not loose. On making a vertical sec.tion, the anchylosis was seen to be of the anterior part of theopposed surfaces of the femur and tibia, the parts of both ircontact posteriorly being necrosed to about the depth of hal;an inch, but without anv well-defined demarcation or indi

cation of separation between the dead and the living parts.There was some displacement and twisting of the tibia in itsrelation to the femur.

, CASE 2.-A delicate strumous boy, ten years of age, wasadmitted into the hospital in July, 1863, suffering from diseaseof the knee-joint. Resection was performed in the followingOctober, the diseased surfaces of the entire joint being re.moved. The case proved tedious, and for a time seemedalmost hopeless, for the patient had a succession of scrofulousabscesses in the elbow and in the neck, and there was noattempt at union in the joint, and his general health sufferedseverely. As the boy had a good home, it was thought thatthe change from the hospital might be of service to him. Hewas accordingly sent home in March of the following year, fivemonths after the operation was performed, with the knee intolerable position, but still discharging at two or three open-ings, and without any consolidation ; in fact, it appeared to beas loose as it was immediately after the operation. Since thenhe has been seen from time to time by Mr. Le Gros Clark, whohad the satisfaction of finding that, by patient perseverance incomplete rest of the joint and tonic treatment, the mobilitygradually diminished, and in September he could bear consi-derable weight on the limb, and the discharge had nearlyceased. A solid leather splint was moulded round the joint,and the splint was then discontinued.The following clinical remarks were made by Mr. Le Gros

Clark :-The foregoing cases present certain points of simi-larity, and others of contrast. In both the diathesis was scro-fulous, and the progress of the disease and reparation tardy.But in one, contrary to expectation, union has been completed;whilst in the other, amputation was rendered necessary, evenafter bony anchylosis, though it proved unavailing in savinglife. When did the necrosis in the first case occur? Thebony anchylosis of the tibia and femur prove considerable re-parative power; yet a portion of the adjoining surfaces hadperished. That there was necrosis or caries was surmisedrather than ascertained, for the dead bone could not be struckwith the probe. And why should one part die, whilst the con-tiguous portions of bone were uniting healthily? It is difficultto answer these questions satisfactorily; but it is abundantlyevident that there was all along some obstacle to the comple-tion of the cure, and that the existing condition of the boneforbad any hope of a speedy separation of the necrosed portion.This part appeared, indeed, to be of unusual density. Thesuccessful issue of the latter case is an encouragement to per-sist in absolute rest, although so long an interval had elapsedbefore any consolidation took place. Unfortunately a large

, proportion of diseases requiring resection of joints are stru-.

mous ; but these cases confirm Mr. Le Gros Clark’s conviction: that they are the least satisfactory class of cases thus to deal’ with. It is worthy of remark that in the first case the patella,

was found firmly anchylosed to the femur.

ROYAL LONDON OPHTHALMIC HOSPITAL.PRIMARY AND SECONDARY SYPHILITIC SORES ON THE

EYELIDS.

(Under the care of Mr. GEORGE LAWSON.)IT is very rare to meet with a primary syphilitic sore on tha

eyelid, though secondary ulcers are not unfrequently seen. Inthe first of the following cases there can be no doubt that thesore on the upper eyelid was a chancre. How inoculationcould have been effected it is difficult to conjecture; but thecombined facts of its syphilitic appearance, its indurated base,the enlarged gland behind the ear, the eruption over the body,and the rapid manner in which it healed under the influenceof mercury, establish beyond a doubt its syphilitic nature.

Secondary sores on the eyelid are often difficult of diagnosis,as in many cases they closely resemble epithelial ulcers; butin cases of doubt, a week or ten days’ treatment with anti-syphilitic remedies will usually decide their true origin. A

I syphilitic sore generally commences close to the tarsal edge ofthe lid, which it partially destroys, leaving a notch which issomewhat characteristic. It will heal at the point where itfirst commenced, whilst it extends in the opposite direction;whereas in the epithelial sore there is no real repair of theulcerated surface: it may scab over in one part, and becomedry; but a re-formation of healthy tissue seldom takes place.The previous history is a very material guide; but syphilis isso often vehemently denied by patients who have suffered from