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THE MEETING AT TUNBRIDGE.
79 HOSPITAL
the results; but it would at
REPORTS.
KING’S COLLEGE HOSPITAL. AMPUTATION AT THE KNEE, WITH CLINICAL BY MR. FERGUSSON.
JOHN R-, aged twenty-four,
was
REMARKS,
admitted into King’s
College
under Mr. Fergusson, 29th Jan. 1845. Has suffered for the last seven years from disease in the left knee-joint, and undergone a great variety of treatment for its cure. In autumn last, an abscess formed over the outer side of the joint, which burst in December, and has continued to discharge matter ever since. The knee is now nearly one-half larger than the other; there is great pain when the articular surfaces are pressed against each other; the thigh and leg are considerably shrunk; there is great pallor of surface, and general emaciation and much depression of the system, from the long continuance of the local
Hospital,
disease. The patient
into the house for the purpose of undergoing but he has been kept under treatment for between four and five months, in hopes that a favourable change might take place. Early in May, it became apparent that, instead of improving, he was gradually getting worse, and it was at last resolved to comply with his wishes, and to amputate the part. Accordingly, on the 17th of May, this was done in the following manner:-The operator, standing on the outside of the came
amputation of the affected part,
of a common flap amputating-knife upon the the inner side of the joint, immediately over the condyle, and made a semi-lunar sweep across the front, extending below the apex of the patella until the point of the blade was opposite the external hamstring, when it was thrust straight across the limb through the popliteal space, and made to appear at the part where the incision in front was commenced; the blade was then carried downwards, so as to form a large flap, from the muscles on the calf of the leg ; the skin in front was now drawn above the level of the upper margin of the patella ; the quadriceps extensor was next divided; a circular sweep was then made round the bone immediately above the condyles, and the saw was used to complete the separation of the limb. A tourniquet had been applied previous to the operation, and little blood was lost during the incisions; a good deal was lost, however, before all the bleeding vessels could be secured, and this seemed principally on account of the difficulty of applying a ligature to the popliteal artery, which, owing to the thickened and hardened condition of the tissues around it, could not be seized and drawn out with the forceps in the ordinary manner. At last, after the application of several ligatures, the bleeding here seemed arrested, and the other smaller vessels were next secured; the large posterior flap was then brought forward, and a few stitches were employed to hold the surfaces and margins together. The wound was lightly covered with lint wetted with cold water, and the house was desired to bring the edges more accurately together in the course of six or eight hours, when it might be concluded that there would be no more bleeding. The after treatment was similar to that which has been reported before as the ordinary practice of the same surgeon. Nothing very unusual occurred; the ligatures were discharged at the usual time; the flaps, which were at first thick, hard, and nearly inflexible, from their proximity to the disease, speedily assumed a more healthy condition, and appeared as if they had been cut originally from parts perfectly sound. Union by the first intention took place throughout the greater part of the wound, the open sores were left gradually to close, and although there are still (10th June) several small points of open surface, and the cicatrix is slightly oedematous, the patient moves about, is greatly improved in appearance and health, and has no complaint whatever connected with his former ailments. In his clinical remarks on this case, Mr. Fergusson stated that he had been induced to select the site of this operation chiefly by the published recommendation of Mr Syme, of Edinburgh, in its favour. That gentleman had performed it on several occasions, and his reports were so favourable, and the proceeding at the same time offered so many seeming advantages, that he deemed the practice well worthy of imitation. The operation at the knee-joint, although successful occasionally, had hitherto proved so unsatisfactory, that few surgeons in this country were inclined to perform it; but this proceeding, it would be remarked, was not actually in the joint, for the saw was carried through the condyles of the femur above, though close to, the articular surfaces, the patella being removed with the lower part of the limb. Whether the narrower extent of bone thus left would be accompanied with less hazard to the patient than when the condyles were allowed to remain, would have to be proved by
limb, placed the heel skin
on
surgeon
’I
once appear that the end of the femur could be more readily covered in the one case than in the other.. Mr. Syme favoured this operation chiefly on the supposition that in consequence of the femur being cut across so close to the epiphysis, there would be less risk of inflammation of the medullary canal, and consequent necrosis of the bone ; and as it was well known that this result (necrosis) was more likely to follow an injury of the hard portion of the shaft than of its spongy extremity, there was on this account great inducement to apply the saw thus low down. But there were other good reasons for choosing such an operation, and not the least of these was, that amputation for certain injuries and diseases in the leg, necessitating the section above the knee, might nevertheless be done so low down-so far from the trunk, comparatively, as to lessen the risk on that account as well; for it was a maxim, that the danger of amputations increased as they approached the trunk. Hitherto, when an operation of this kind had been done above the knee, the knife had been so applied as to reserve all the soft parts to form the stump from the thigh alone; but here it would be remarked, that the flap for a stump of the thigh had been taken from the leg, where, in such an instance as that which was at present under notice, there was ample material for making a flap of any extent that might have seemed desirable. In accidents, and in all diseases of the leg, when amputation in the was requisite, it was not improbable that such a proceeding as this might prove a valuable acquisition to surgery; and even in most of the diseases of the knee-joint necessitating this last resource, it might possibly be proved to be a preferable proceeding to the section higher up. The swelling of a joint, wherein the articular surfaces and ends were in a state of ulceration and caries, had been proved to depend entirely on these diseased conditions, as had been evinced by excisions of such parts, and it was a doctrine of modern surgery, that in removing caries, there was no necessity for reaching beyond the actual seat of the disease. There were many examples of incurable affection of the knee-joint which might possibly be best treated by such a mode as had been followed in this instance. One objection to the operation was apparent at the time it was done, and that was, the difficulty of securing the popliteal artery. The’vessel was so surrounded by effused lymph, and condensed cellular tissue, that he had to slit up the tissues ere he could seize the vessel with the forceps, and even then, it was with no inconsiderable trouble that he could get a ligature placed so as to stop the flow of blood. That had been done, however, after several unsuccessful attempts, and the pupils had all had the opportunity of seeing how completely the swelling of the soft parts had subsided since the removal of the source of irritation. The stump was now an excellent one for its age, and the results in this case had been such as to encourage him to follow a similar proceeding in the next eligible case that might fall under his
thigh
notice.
THE MEETING AT TUNBRIDGE. To the Editor of THE LANCET. SiR,-Mr. Bottomley, in his communication to THE LANCET of the 5th inst., relative to the meetings at Tunbridge and Brighton, is so incorrect in his statements, particularly in those parts of his letter relating to myself, that I must request of you permission to undeceive him and the readers of TiiE LANCET. In the first place, I give him credit for good intentions, and not a desire to mislead his professional brethren. Secondly,’at the Tunbridge meeting I did not read one word from the Transactions of the National Association of General Practitioners, but three clauses* of the amended Bill of Sir James Graham, respecting the power given by it, to members of the College of Surgeons of London, to register as surgeons. Thirdly, Mr. Bottomley must have been misinformed as to the number of surgeons, or general practitioners, in Brighton. Instead of 110, there are but fortyeight or forty-nine; thirty-one of whom signed the petition agreed to at, and acquiesced in the proceedings of, the meeting to which Mr. Bottomley alludes; which meeting was convened by advertisement in all the local papers, and by circular, to every general practitioner in this district, which makes whatever was done by that meeting the voice of the general practitioners of this town and
46, Old
neighhourhood.
,
I am, Sir, your obedient servant, J. CORDY BURROWS, Steyne, Brighton, July]4tb, 1845.
Surgeon.
* Probably Mr. BURROWS will furnish us with the numbers of the clauses in question, and explain their purport, in connexion with the official statement of Sir J. GRAHAM, addressed to Mr. HonNE, that it was his intention to provide in the Bill, that the fees and remuneration of "registered surgeons" should be merely " honorary."-ED. L.
the results; but it would at
REPORTS.
KING’S COLLEGE HOSPITAL. AMPUTATION AT THE KNEE, WITH CLINICAL BY MR. FERGUSSON.
JOHN R-, aged twenty-four,
was
REMARKS,
admitted into King’s
College
under Mr. Fergusson, 29th Jan. 1845. Has suffered for the last seven years from disease in the left knee-joint, and undergone a great variety of treatment for its cure. In autumn last, an abscess formed over the outer side of the joint, which burst in December, and has continued to discharge matter ever since. The knee is now nearly one-half larger than the other; there is great pain when the articular surfaces are pressed against each other; the thigh and leg are considerably shrunk; there is great pallor of surface, and general emaciation and much depression of the system, from the long continuance of the local
Hospital,
disease. The patient
into the house for the purpose of undergoing but he has been kept under treatment for between four and five months, in hopes that a favourable change might take place. Early in May, it became apparent that, instead of improving, he was gradually getting worse, and it was at last resolved to comply with his wishes, and to amputate the part. Accordingly, on the 17th of May, this was done in the following manner:-The operator, standing on the outside of the came
amputation of the affected part,
of a common flap amputating-knife upon the the inner side of the joint, immediately over the condyle, and made a semi-lunar sweep across the front, extending below the apex of the patella until the point of the blade was opposite the external hamstring, when it was thrust straight across the limb through the popliteal space, and made to appear at the part where the incision in front was commenced; the blade was then carried downwards, so as to form a large flap, from the muscles on the calf of the leg ; the skin in front was now drawn above the level of the upper margin of the patella ; the quadriceps extensor was next divided; a circular sweep was then made round the bone immediately above the condyles, and the saw was used to complete the separation of the limb. A tourniquet had been applied previous to the operation, and little blood was lost during the incisions; a good deal was lost, however, before all the bleeding vessels could be secured, and this seemed principally on account of the difficulty of applying a ligature to the popliteal artery, which, owing to the thickened and hardened condition of the tissues around it, could not be seized and drawn out with the forceps in the ordinary manner. At last, after the application of several ligatures, the bleeding here seemed arrested, and the other smaller vessels were next secured; the large posterior flap was then brought forward, and a few stitches were employed to hold the surfaces and margins together. The wound was lightly covered with lint wetted with cold water, and the house was desired to bring the edges more accurately together in the course of six or eight hours, when it might be concluded that there would be no more bleeding. The after treatment was similar to that which has been reported before as the ordinary practice of the same surgeon. Nothing very unusual occurred; the ligatures were discharged at the usual time; the flaps, which were at first thick, hard, and nearly inflexible, from their proximity to the disease, speedily assumed a more healthy condition, and appeared as if they had been cut originally from parts perfectly sound. Union by the first intention took place throughout the greater part of the wound, the open sores were left gradually to close, and although there are still (10th June) several small points of open surface, and the cicatrix is slightly oedematous, the patient moves about, is greatly improved in appearance and health, and has no complaint whatever connected with his former ailments. In his clinical remarks on this case, Mr. Fergusson stated that he had been induced to select the site of this operation chiefly by the published recommendation of Mr Syme, of Edinburgh, in its favour. That gentleman had performed it on several occasions, and his reports were so favourable, and the proceeding at the same time offered so many seeming advantages, that he deemed the practice well worthy of imitation. The operation at the knee-joint, although successful occasionally, had hitherto proved so unsatisfactory, that few surgeons in this country were inclined to perform it; but this proceeding, it would be remarked, was not actually in the joint, for the saw was carried through the condyles of the femur above, though close to, the articular surfaces, the patella being removed with the lower part of the limb. Whether the narrower extent of bone thus left would be accompanied with less hazard to the patient than when the condyles were allowed to remain, would have to be proved by
limb, placed the heel skin
on
surgeon
’I
once appear that the end of the femur could be more readily covered in the one case than in the other.. Mr. Syme favoured this operation chiefly on the supposition that in consequence of the femur being cut across so close to the epiphysis, there would be less risk of inflammation of the medullary canal, and consequent necrosis of the bone ; and as it was well known that this result (necrosis) was more likely to follow an injury of the hard portion of the shaft than of its spongy extremity, there was on this account great inducement to apply the saw thus low down. But there were other good reasons for choosing such an operation, and not the least of these was, that amputation for certain injuries and diseases in the leg, necessitating the section above the knee, might nevertheless be done so low down-so far from the trunk, comparatively, as to lessen the risk on that account as well; for it was a maxim, that the danger of amputations increased as they approached the trunk. Hitherto, when an operation of this kind had been done above the knee, the knife had been so applied as to reserve all the soft parts to form the stump from the thigh alone; but here it would be remarked, that the flap for a stump of the thigh had been taken from the leg, where, in such an instance as that which was at present under notice, there was ample material for making a flap of any extent that might have seemed desirable. In accidents, and in all diseases of the leg, when amputation in the was requisite, it was not improbable that such a proceeding as this might prove a valuable acquisition to surgery; and even in most of the diseases of the knee-joint necessitating this last resource, it might possibly be proved to be a preferable proceeding to the section higher up. The swelling of a joint, wherein the articular surfaces and ends were in a state of ulceration and caries, had been proved to depend entirely on these diseased conditions, as had been evinced by excisions of such parts, and it was a doctrine of modern surgery, that in removing caries, there was no necessity for reaching beyond the actual seat of the disease. There were many examples of incurable affection of the knee-joint which might possibly be best treated by such a mode as had been followed in this instance. One objection to the operation was apparent at the time it was done, and that was, the difficulty of securing the popliteal artery. The’vessel was so surrounded by effused lymph, and condensed cellular tissue, that he had to slit up the tissues ere he could seize the vessel with the forceps, and even then, it was with no inconsiderable trouble that he could get a ligature placed so as to stop the flow of blood. That had been done, however, after several unsuccessful attempts, and the pupils had all had the opportunity of seeing how completely the swelling of the soft parts had subsided since the removal of the source of irritation. The stump was now an excellent one for its age, and the results in this case had been such as to encourage him to follow a similar proceeding in the next eligible case that might fall under his
thigh
notice.
THE MEETING AT TUNBRIDGE. To the Editor of THE LANCET. SiR,-Mr. Bottomley, in his communication to THE LANCET of the 5th inst., relative to the meetings at Tunbridge and Brighton, is so incorrect in his statements, particularly in those parts of his letter relating to myself, that I must request of you permission to undeceive him and the readers of TiiE LANCET. In the first place, I give him credit for good intentions, and not a desire to mislead his professional brethren. Secondly,’at the Tunbridge meeting I did not read one word from the Transactions of the National Association of General Practitioners, but three clauses* of the amended Bill of Sir James Graham, respecting the power given by it, to members of the College of Surgeons of London, to register as surgeons. Thirdly, Mr. Bottomley must have been misinformed as to the number of surgeons, or general practitioners, in Brighton. Instead of 110, there are but fortyeight or forty-nine; thirty-one of whom signed the petition agreed to at, and acquiesced in the proceedings of, the meeting to which Mr. Bottomley alludes; which meeting was convened by advertisement in all the local papers, and by circular, to every general practitioner in this district, which makes whatever was done by that meeting the voice of the general practitioners of this town and
46, Old
neighhourhood.
,
I am, Sir, your obedient servant, J. CORDY BURROWS, Steyne, Brighton, July]4tb, 1845.
Surgeon.
* Probably Mr. BURROWS will furnish us with the numbers of the clauses in question, and explain their purport, in connexion with the official statement of Sir J. GRAHAM, addressed to Mr. HonNE, that it was his intention to provide in the Bill, that the fees and remuneration of "registered surgeons" should be merely " honorary."-ED. L.