across the left iliac region, so as to overlap the crest of the ilium. There was a strong pulsation throughout the whole extent of the tumour, great pain in the course of the crural nerve, and considerable cedema of the thigh.

On the 20th, chloroform having been administered, the cavity was examined by introducing first one finger, then another, and finally the whole hand, without any trace of the artery being detected, whence it was concluded to be out of its usual situation. A screw clamp provided by Professor Lister, of Glasgow, was then employed to effect compression of the aorta; and this having been ascertained to be complete, a free incision was made through all the textures concerned, so as to lay the sac fully open, and allow six pounds of blood and clots to be scooped out. It then appeared that the arterial orifice was in the roof of the aneurism, from the vessel having been raised in this direction by the blood effused under it; and this orifice, being brought distinctly into view by dissection of the sac, was tied on both sides of the vessel. But as blood still issued, though not with the same force as before the ligatures were applied, it was concluded that the internal iliac originated from the portion of artery comprehended between them; and this vessel also having been exposed, was tied by a thread passed round it. The wound was then dressed superficially, and everything went on favourably. On the nineteenth day the ligatures separated, and the cavity gradually contracted.

After relating this case some observations are made-1. On the importance of ascertaining that the aorta could be effectually compressed so as to prevent hæmorrhage from its primary branches. 2. On the sac not maintaining a profuse and protracted suppuration like the investment of a chronic abscess, but readily contracting so soon as the distending force ceased to act. 3. On the impossibility of affording relief in the case related by any other means than the one employed, and the danger which would have attended ligature of the common iliac at an earlier period from the aperture being so near the bifurcation.

In conclusion, the author expresses hope that the cases of carotid, axillary, gluteal, and iliac aneurisms which have been under his observation would induce teachers of surgery to reconsider the propriety of representing the Hunterian operation as so exclusively the rule of practice as it has hitherto been regarded.

On the Mortality after excision of the Knee, as practised hitherto in London.

By Mr. T. HOLMES, Surgeon to the Hospital for Sick Children, and Assistant-Surgeon to St. George's Hospital.

(Medico-Chirurgical Review, July, 1862).

In this paper, Mr. Holmes supplies information of a very startling character, namely this-that the operation of excision of the knee, instead of having been less fatal than amputation of the thigh, has turned out in general practice certainly, and, in the practice of the London hospitals most probably, more than twice as fatal as that

operation, and that in both classes of cases its failures appear to have been more numerous than its successes. The information supplied is obtained partly from an excellent essay on "The Excision of the Joints," by Dr. Richard M. Hodges, recently published in America, and partly from data which have been collected by Mr. Holmes himself from the records of the various metropolitan hospitals. Dr. Hodges, in his essay, has brought together from all sources no less than 208 cases of excision of the knee for chronic disease. Of these cases, in round numbers, one-third died; more than half are known to have failed; and there is no direct evidence of success in more than one-third of the cases, even accepting the statements of those who furnished the notes. The exact numbers are these: 60 were directly fatal without amputation, and 9 others were known to have died after amputation; the whole number of those who underwent amputation was 42; in 14 other cases the limb is stated to have been more or less useless :-thus, making the whole number of known failures 116. In 27 other cases there is no information on the subject of the usefulness of the limb, the simple statement of "recovery' being all that is given. In the remaining 65, the accounts furnished represent the patient as having obtained a useful limb. The mortality taken at 69 is a minimum, since of the 42 amputated only 35 are accounted for, the result being left uncertain in the other 7 The number of failures, if taken at 116, is also a minimum, since it is all but certain that some of the 27 unaccounted for must have failed; while, in admitting the fact of success in the 65 cases in which it is claimed, we are leaving out of view the great tendency of advocates of a given plan of treatment (and nearly all those who furnished the notes are in this position) to overestimate the success of their favourite plan, as well as the great frequency of occurrences which afterwards spoil a union that seemed useful at first, such as gradual yielding and flexure backwards or sideways, recurring disease, interrupted growth in childhood, &c.

cases.

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No one," says Mr. Holmes, "would think of comparing such success as this with the results of amputation in metropolitan hospitals; siuce it has been clearly proved that the rate of death in amputation of the thigh, at its lower part, for chronic disease of the knee, is about one-seventh of the number of cases-and of those who recover, hardly any are not relieved from local disease, irritable and diseased stumps being rare in this amputation. Several objec tions, however, may be made to the comparison between Dr. Hodges' statistics and those of amputation in London hospitals, all of which objections may be included in the statement that the two series of cases were not under the same conditions. But no such objections could be raised against a comparison instituted between a complete series of the cases of excision of the knee-joint treated in the metropolitan hospitals, and those of amputation of the thigh in the same institution, since the patients were of the same class, subjected to the same influences of habits and constitution, under the same surgical treatment, and in the same atmosphere. I had wished, therefore, to procure satisfactory data of all the cases of excision treated at all the metropolitan hospitals, including the following under that

term: St Bartholomew's, Guy's, St. Thomas's, King's College, St. George's, University College, the Westminster, the Middlesex, the London, Charing-crcss, St. Mary's, the Hospital for Sick Children, the Great Northern, and the Royal Free Hospital.

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"I much regret, however, that the defective method in which statistics are kept at nearly all our hospitals (I might say, the utter absence of all attempt to keep such statistics in many of them), has disappointed me in this attempt. Still, though baffled in my attempt to obtain complete statistics, I have succeeded in procuring a considerable list of authentic cases-in fact, one which includes the very great majority of the operations which have been performed at the above-mentioned hospitals. This list may be taken as nearly correct for the number of deaths in the cases comprised in it, and it may perhaps, without serious error, be accepted as showing the percentage of deaths which would prevail in the series, if it could be completed. I believe, also, that the number of secondary amputations is correct for the cases included in the list. But the details which would show the usefulness of the limb in those cases which recovered --which I regard as the most important point of all—are, I am sorry to say, not to be obtained in sufficient numbers to allow of any sound deduction being made. Hence, although I have to thank the surgical authorities of all the hospitals for the greatest courtesy and liberality in allowing me to make use of such materials as they possess, I am compelled to say that these materials are insufficient, and that the following list will give only negative results-i.e., it will show the minimum of ill success which may have attended the operation as practised in London, but will give no reliable data as to the number of useful limbs which were really turned out by the 95 operations of which it is composed. It may be interesting to add the numbers, as showing the great diversity of opinion which must preVail among hospital surgeons as to the propriety of performing the operation. Of the 95 cases, 32 are from King's College Hospital, 14 from St. Thomas's, 13 from University College, 6 from the Great Northern, 5 from St. George's, 5 from the Westminster, 3 from St. Bartholomew's, 3 from Guy's, 3 from Charing Cross, 3 from the Hospital for Sick Children, 2 from the Middlesex, 2 from St. Mary's, 2 from the London, and 2 from the Royal Free Hospital. Of these 95 patients, 27 are known to have died; and in 10 others the operation failed, as shown in 8 cases by amputation, and in the other two by the limb being reported as useless, though it is not known to have been removed. This would make the minimum rate of mortality 28 4, and the minimum rate of failure 38.9 per cent. But out of the 58 remaining cases the accounts of 10 are either unsatisfactory, leading to the suspicion that the limb was not useful, or are entirely vague; while of 19 of the others, forming a portion of the King's College series, I have only the most summary account; and although I know that many of these operations succeeded, some, I have no doubt, must have failed. Hence we may suspect that no better success has attended the operation in the hands of the hospital surgeons of London than in those of other operators, and that as many of the cases have failed as have succeeded.

"Now, it is by no means my intention, in writing these few lines, to dwell on the failures of a novel method of treatment, still less to decry or to endeavour to banish from practice an operation which, on the contrary, I hold, in properly-selected cases, to be extremely useful. I only wish to show how very fallacious the statements which have been hitherto made as to its relative mortality, when compared with that of amputation, have been; how uncertain we really are what benefits have resulted in the so-called successful cases; and as a consequence from these facts, which, I presume, will soon be patent and admitted by every one, how urgently needed is some better plan of keeping the records of our great hospitals, if the ample experience which might be collected from them is to be made available to the great body of the profession. The exaggerated and inconsiderate assertions which were made of the incredible success of excision of the knee by its earlier and warmer advocates, have done much to discourage more sober-minded practitioners from an operation which, had it not been unduly extolled, would sooner have come into more extended, though perhaps less indiscriminate use; and these assertions would probably have never been received as true, had authentic hospital statistics been at hand by which to test them. At present, the operation is in danger of being discredited by failures which perhaps are not essential to its performance. We are told, and with great probability, that the recent mortality after the operation shows signs of diminishing, that the selection of cases fitted for the operation is now better understood, that the importance of certain rules for the performance of the operation and its after-treatment, is now recognised and acted upon, and so that fewer patients will die, and those who recover will do so with more useful limbs. I sincerely hope that it may be so, and I am anxious to believe that it will; but we cannot forget that we were told far more confidently, as a matter of fact, a few years ago, that the operation had proved more successful in both these particulars than amputation; and if that assertion had any foundation in fact, the present altered condition of things can only have been brought about by the cases of excision having turned out less successful recently.”

Practical Lithotomy and Lithotrity; or an Inquiry into the best modes of removing Stone from the Bladder.

By HENRY THOMPSON, Esq., F.R.C.S., Assistant-Surgeon to University College Hospital, Consulting Surgeon to the St. Marylebone Infirmary, &c., &c.

(London: John Churchill & Sons. 1863. Pp. 274.)

The greater part of this work has already appeared in the pages of the Lancet as the "Lettsomian Lectures" for 1862; but this fact has not done away with the necessity for publication in a more convenient and accessible form. On the contrary, the articles in the

journal have only served to bring out this necessity for separate publication in the most conclusive manner possible.

The description of the anatomy of the parts concerned in the operation of lithotomy is both accurate and to the point. In this part we do not expect much novelty, but there is one point which is certainly new, and which we commend to anatomists and accoucheursnamely, this, that the proper simile for the male pelvic outlet is neither the triangle nor the lozenge, but the conventional heartthe ace of hearts, with the apex upwards.

The description of the instruments necessary for lithotomy, and of the operation itself, is clear and accurate, and the discussion upon the advantages and disadvantages of the various modes of operating is well calculated to bring out the truth. With respect to the operation which has lately been revived extensively-Allerton's median operation, Mr. Thompson says:

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Of all the cutting operations for stone, it is unquestionable that the median still presents that in which the bladder is reached with the smallest amount of section by the knife. And it appears to become dangerous just in proportion as injury by laceration, or over-pressure under the name of dilatation, is superadded to the incisions. These latter involve the bulb to a small degree, which is the only structure of importance divided by the knife besides the prostate, and this latter is only notched at the apex in the ordinary mode of performing the operation. But when the deeper parts feel more than usually rigid and unyielding, or when the stone proves to be larger than was anticipated, it is advisable to make an incision in the left side in the same direction as in lateral lithotomy, but generally less extended, for the purpose of affording space. This is accomplished after the urethra has been opened, by introducing a long straight probe-pointed bistoury, guided by the left index finger, and made to incise as much as the operator deems necessary. Unless this or some similar proceeding be adopted, the opening is certainly small and feels tight to the finger, and if the stone is large, appears to me to require an additional incision.

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After all, the anatomical axiom laid down at first must not be forgotten, viz., that any operation the incisions of which lie altogether in the line above the anus and below the symphysis pubis, unless aided by a lateral section, never can afford an opening sufficiently capacious for the removal of very large stones without dangerous laceration. Examine the pelvic outlet, and contrast the want of space in this situation caused by the converging pubic rami, with the room which exists in one of its lateral divisions, and the correctness of this assertion will, I think, be manifest."

We fully agree with Mr. Thompson in believing that the danger of infiltration of urine after lithotomy is much exaggerated, and that, when after death suppuration and infiltration are found, the urinary extravasation is not the primary cause of the inflammation, but vice versâ.

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Infiltration by no means necessarily occurs when urine passes over the newly-made section of cellular spaces so called. In fact, cellular interspaces between muscles and between viscera do not

XXXVII.

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