2nd. The adoption of such measures
as may be conducive to the ad-
vancement of medical science and
of professional information.
3rd. The periodical assemblage of
the members for literary and scien-
tific discussion-for the cultivation
of social intercourse, and for the
consideration of general measures
relative to the Society.
4th. The creation of a fund to be
appropriated to the protection of
the Members, and for the general
exigencies of the Society.
5th. The establishment of a benevo-
lent fund, by contributions from
Members of the Profession at large
and other charitable persons, for
the relief of distressed medical
men and their families.

The limits of a prospectus will not allow of a full detail of the objects contemplated; but it may be observed, in addition to the foregoing general statement, that it is intended, as soon as practicable, to effect some regulation

gaged, as early as possible, for the use of the Society.

The Society will meet at such stated periods, and in such manner, as will be hereafter determined.

The foregoing is a brief statement of the views of the Founders of this Society, and of the advantages intended from its institution, the Plan of which may be enlarged, or curtailed, according to the support it may receive.

The Committee of Management entertain a confident hope that the Society will be of great utility to the general body of Practitioners, whose attention to this subject is earnestly recommended.

WILLIAM GAITSKELL, President. It is requested that all applications and communications be made and addressed (post paid) to Mr. W. SENHOUSE GAITSKELL, Solicitor, 21, Stamford Street, Blackfriars.

XLII.

OTHER NERVES.

Review, London.

Notwithstanding that there are numerous charitable funds for relieving distressed members of particular branches of the Medical profession, it is found that there are many Members of that Profession who are not objects of relief from any of those funds; and it is, therefore, to supply this desideratum, that the Plan of a General Benevolent Fund has been adopted, the application of which, it is intended, should not be confined to this Society exclusively, but should be extended, at the discretion of the Committee, to every Member of the Profession.

The affairs of the Society are under the management of a President, VicePresident, and a Committee.

A House, or Chambers, will be en

Sir, I observe in your fasciculus for February last, the description of an operation performed by Dr. Warren, for excision of the submaxillary nerve, extracted from the Boston Medical and Surgical Journal. This mode of operating appears truly formidable, and is probably that which the late Dr. Haighton had in view, when he pronounced the division of this nerve impracticable.

A much simpler, safer, and easier mode of accomplishing the división of this nerve, where it enters the canal of the inferior maxillary bone, is, to make an incision, with a scalpel, from within the mouth to the extent of an inch, through the mucous membrane and cellular tissue connecting the pterygoideus internus muscle, to the ramus of the bone, parallel and close to the inner or mesial surface of the coronoid process immediately behind the dens sapientiæ; then to take a round-shaped gum lancet and carry it backwards in a line continuous with the crowns of the molar

teeth, having the cutting edge at right angles to the bone, and divide the nerve on the bone. The pain experienced on the division of the nerve, at once, indicates that the proper organ has been cut. As the internal maxillary artery ascends to the bulbous process of the superior maxillary bone, it cannot be wounded, excepting through ignorance or carelessness; but, even if it were, a piece of dry sponge might be easily inserted to stem the hæmorrhage. The gustatory branch of the nerve could scarcely be injured. The dental artery must be wounded, but this is so small as to be of no moment, and, if morbidly enlarged, dry sponge would compress it. I have now performed this operation on four patients for neuralgia of the mental nerve, with perfect success, having previously attended to the chylopoietic viscera, and then tried the various antispasmodics and subcarbonate of iron; also the different counterirritants, even the moxa, and lastly, the division of the nerve as it emerges at the mental foramen. Or, according to your own showing-" after the local symptoms from morbid associations or change of structure, had continued after the constitutional derangement from which they originally emanated, had been rectified-and the consequence had survived the cause." My first case was published in the Edinburgh Medical and Surgical Journal for October, 1821.

Thus there would appear to be a material difference between the division of the trunk of a nerve, where it is protected from the vicissitudes of atmospherical influence by muscular and other soft coverings, and the division of the same nerve, where it is exposed to the alternations of the weather, as far as relates to the permanent salutary result. It is well known, that in neuroma supervening to amputation, the excision of the tumor or tumors, proves a more permanent or radical cure than a secondary amputation, also in neuralgia following the same operation, excision of the nerves does the same, and evidently in consequence of excision preventing the interesting junction of the nerves, as well as the production

of the numerous delicate filaments supplying the cicatrix of the stump. This has been satisfactorily described by Larrey in his late valuable work Clinique Chirurgicale,' and also by Descot, in his interesting Dissertation sur les Affections Locales des Nerfs.' For the same reasons, the excision of a portion of a nerve must be a more effectual cure than simple division of the same.

If this view of the operative department of the pathology of nerves be found to be correct, it would follow, that the division of the infra-orbitary nerve, where it enters the osseous canal in the floor of the orbit, would prove more availing, than its division at the infra-orbitary foramen on the cheek. This might be easily accomplished as follows:-let an incision about an inch long, of a curvilinear figure, to correspond with the circular shape of the orbit, be made at the outer canthus of the eye, the centre of which shall be opposite the outer commissure or angle of the eye-lids, or rather the superior margin of the zygoma. This incision is to be deepened by cutting close to the osseous wall of the orbit, until the instrument reach the spheno-maxillary fissure, when it is to be laid aside, and a round shaped gum lancet inserted in the wound with its cutting edge at right angles to the floor of the orbit, and the nerve divided as it runs in the osseous channel. In some, this is an open, while in others, it is a shut or entire canal; but, in all, the parietes are so delicate as to be easily cut across. A portion of the infra-orbitary nerve, at its emergence from the infra-orbitary foramen, could not be removed, in consequence of its division into so many minute filaments: neither could this be accomplished within the orbit.

The supra-orbitary or frontal nerve may be also divided within the orbit, nearly an inch from the superciliary ridge, by first ascertaining the superciliary foramen or notch, which is done by drawing a perpendicular line from the second bicuspis at right angles to the area of the crowns of the teeth; secondly, by making an incision about the fourth of an inch parallel and close

to the superciliary ridge at the foramen, through the integuments, orbicularis palpebrarum muscle, and ligament of the superior tarsus; thirdly, substituting for the straight bistoury or scalpel, a probe-pointed bistoury, which is to be inserted deep in the orbit close to the bone, and with which the nerve is to be divided by cutting upwards on the bone, in the direction from the inner to the outer canthus, carefully guarding against injuring the superior oblique muscle on its inner or mesial aspect. A portion of this nerve may be excised

either within or without the orbit: within, as just directed, combined with searching for the nerve at the superciliary foramen, and after its division seizing hold of it with the dissecting forceps and removing the insulated or detached part. As it sends off minute filaments on its emergence from the orbit, the removal of a portion without the cavity, would not hold out a prospect of so permanent a cure.

JOHN LIZARS Edinburgh, 34, North Place. 24th April, 1830.

XLIII.

EDINBURGH SURGICAL HOSPITAL.*

EXCISION OF JOINTS.

SINCE November 1828, when Mr. Syme cut out a carious elbow, which he complacently remarks, "was the first time the operation was ever performed in Great Britain,” he has operated in six other cases. Five of these seven cases have already been recorded in our respected Northern contemporary, and Mr. S. now furnishes the remaining two, of which we shall place an account before our readers.

Case 1. "Elizabeth Johnston, æt. 15, from Falkirk, entered the Hospital on the 26th of August, on account of a disease of the right elbow-joint, which had existed for six months, commenced spontaneously, and increased progressively, notwithstanding the efforts of her medical attendants. It now presented a most formidable appearance, the joint being so much swelled as to measure thirteen inches in circumference, and the arm above being reduced to little more than skin and bone, which made the enlargement seem even greater than it really was. The skin over the olecranon was extensively ulcerated,

and at different places, both on the front and back parts of the joint, the probe could be passed into sinuses which extended to the bones. The limb was straight, and nearly immoveable. The discharge was profuse, the pain unceasing, and the irritation so great that the patient's health seemed rapidly sinking. It was plainly necessary to do something effectual for her relief, and both Dr. Ballingall and I, though entertain ing the most favourable opinion of excision, from what we had seen of its good effects, resolved that any opera tion short of amputation would be inexpedient in this case, where there was such extensive disease not only of the bones, but also of the soft parts. Being, however, very averse in general to amputating the arm for caries, and feeling particular reluctance to mutilate this unfortunate girl, who was distinguished by the most amiable disposition and interesting appearance, I delayed the operation. In the course of ten days, whether it was owing to a real improvement proceeding from the free vent which had been afforded to the matter by incisions, or was merely the effect of familiarity with the appearance of the joint, I fancied that it was not so hopeless as at first believed, and re-' solved to make an attempt at excision.

The operation was performed in the manner formerly described, and was at

soft parts from the articulating bones, which had been caused by collections of matter. The olecranon was greatly expanded, and, if I may use the expression, completely rotten, so that it crumbled into fragments, which were extracted piecemeal. The radius adhered to the humerus, and was extracted along with it. Before dressing the

wound, I observed that the ulnar nerve was partially divided by an oblique incision, and therefore cut it completely across, to avoid the danger of such a wound; and its extremities being then placed in contact, the integuments were stitched together. The patient did extremely well; the wound healed most kindly; the swelling of the joint subsided; she gradually regained its use; and is now, I am happy to understand, restored to perfect health. For some time after the operation, she complained of coldness and numbness in the ulnar side of the hand, but in process of time got rid of these unpleasant symptoms, probably in consequence of re-union between the extremities of the nerve."

Case 2. James Page, æt. 8, was admitted on the 2d of January, as a proper subject for excision of the right elbow-joint, which was much enlarged, discoloured, and stiff, with two sinuses opening on each side of the triceps, through which a probe could be passed to the bone. The operation was performed in the ordinary way on the 12th January, the wound healed kindly, and the patient is nearly ready to leave the hospital.

In the case of a lad at present in the house the operation is only delayed till the parents' consent is obtained. In another case, in which the olecranon appeared to be extensively affected with superficial caries, the bone was exposed by Mr. Syme, and the softened portion removed with a gouge; the wound is now nearly healed and the patient makes no complaint. So much for excision of the elbow-joint, and we next proceed to that of the knee. Let us hear what Mr. Syme has to say upon the subject.

"The knee-joint, so far as regards its structure, is an equally favourable subject for excision with the elbow,

since there is only one articulation concerned in the disease or affected by the operation, and not a number, as is the case in the wrist or ankle. But the advantages from the operation in this situation are much more questionable than in the shoulder or elbow, since not only is there much less difference between the utility of a natural leg and a wooden one, than between that of a real and artificial arm, but doubts may even be entertained as to the proba bility of deriving any assistance in progressive motion from the limb, which is preserved by cutting out the kneejoint. With the exception of the two cases operated upon by Mr. Park of Liverpool, nearly fifty years ago, and the two cases lately published by Mr. Crampton of Dublin, I am not acquainted with any recorded facts to guide us in deciding this question. Each of these gentlemen lost one of their patients, but the others survived and retained limbs so useful, that the owners would not readily have exchanged them for artificial ones. Mr. Park's patient, a sailor, was able to ascend the rigging of his ship with the agility peculiar to that profession; and the woman on whom Mr. Crampton operated could walk the distance of eight or nine miles without suffering fatigue or inconvenience.

The advantages attending excision of the knee-joint over amputation in the thigh, in addition to the satisfaction of saving a limb, and promoting the credit of surgery, seem to me, First, The negative one of saving the patient from the inconvenience of resting his weight upon the face of a stump: Secondly, The positive one of preserving for him the tarsus, metatarsus, and toes, which constitute an apparatus much more efficient in protecting against the effects of concussion than any artificial one that can be constructed. Influenced by these considerations, I resolved to try the operation in some of those cases of diseased knee which so frequently result from white swelling in young subjects, and are condemned without any ceremony to amputation."

Case. J. Arnott, æt. 8, was admitted

Dec. 1st, with the left knee very much enlarged, and immoveably bent at an acute angle with the thigh; there were two sinuses leading to the bone on the inner side of the joint, the health was broken, and " he seemed to be devoted to speedy destruction." The disease was of three years' duration, and had resulted from a fall on the ice.

On the 7th Mr. Syme made two incisions across the fore-part of the joint, extending from one condyle of the femur to the other, meeting at their extremities, and including the patella between them. The included integuments and patella, which was much diseased, being removed, the extremity of the femur was exposed and sawed off, but in doing this the periosteum was separated too much from the bone, and another portion of the latter was taken away. The bead of the tibia was next exposed and removed by cutting pliers, one of the articular arteries tied, the wound dressed, and the limb extended by splint and bandage as far as the contraction of the hamstring muscles would allow. Exfoliation of the tibia was threatened and things at first wore a gloomy aspect, but by cautious extension and counter-extension the displaced extremities of the bones were reduced, the limb became straight, the wound in four weeks was nearly healed, and the limb is daily becoming more useful to the patient.

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Case 2. Ann Mackintosh, æt. 7, was admitted Dec. 14th, "on account of a white-swelling of the right knee, which had existed eighteen months, and was now in its last stage;" there was a large sinus above the inner condyle, through which Mr. S. introduced his finger into the joint and felt it extensively diseased. Mr. S. performed an operation similar to that in the former case, and, as in that, the removed articulating portions of bone were extensively ulcerated and carious. "The soft parts, however, were much less swelled and less altered by the gelatinous degeneration of scrofulous action than in the boy's case; the result, therefore, was expected to be, if possible, still more satisfactory." But it was not so,

for the difficulty of preventing dislocation of the bones was great, the femur, so far as it was visible, presented a bare and dead-like surface, and when Mr. Syme, in order to check more effectually the tendency to displacement, cut away about two inches more of the femur with the pliers, he was astonished to find that the bone was extensively denuded. Amputation now appeared to be the only means left, but our author waiting a little "in the expectation of nature pointing out at what part of the limb the operation ought to be performed," the patient gave Nature and Mr. Syme the slip, by dying in the interim.

"I do not think that the enemies of excision can found any thing on this case, since it would appear from reasoning, and has been in great measure proved by experience that excision of a joint is less dangerous than amputation of the limb; and the only question that can be agitated in respect to the merits of the operation in this situation concerns the utility of the limb which is preserved."

We are disposed to differ from Mr. Syme in this sentiment, for we fear that the enemies of excision and the excisor might found a good deal upon the case, and a superstructure too of a very disagreeable nature to Mr. S. We must confess that more meagre details, and more questionable observations could scarcely have been put together on the occasion. We are told in the commencement, that the case was one of "white swelling," which means any thing or nothing-we are told, that the prognosis from an operation is satisfactory, because the soft parts are comparatively little altered by the gelatinous degeneration of scrofulous action; a gelatinous degeneration of an action! We are told that because the femur is denuded farther than the finger can reach, amputation is the only chance, but that amputation is delayed till Nature points out the part of the limb, where the knife shall be applied. We know not whether Mr. Syme, like Numa, in the Roman days, may have found in the grots of the surgical hospital, an Egeria denied to his brethren, but cer

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