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ed, he found articular dropsy in three; in two, there was a single dislocated hip; and in the third case the dislocation was double.
2. Foetal Diseases not affecting the Articular Surfaces.—Diseased conditions of the skeleton, as seen in rickets, &c, may determine secondarily deviations or serious malformations of the joints. Others may arise from a contraction of the ligaments or aponeuroses. M. Robert has several times observed congenital lateral deviations of the fingers or great toe combined with a shortened condition of the lateral ligaments. All observers have insisted upon the existence of the contraction of muscles. But while most of these have regarded this action of the muscles as primary and causative, they have done so with very different views. Guerin, studying congenital deformities on a large scale in correlation with monstrosities of the nervous system and convulsive affections of the foetus, lays it down as a fundamental fact, that the convulsive muscular retraction or continued tension of the muscles is due to a lesion of the nervous system. Once established, this muscular retraction becomes permanent. At first the texture of the muscles affected by it undergoes no change, but continues as red, firm, and voluminous as in the normal state. This first stage is called by Guerin, contraction. But at a later period the muscles gradually undergo alteration, and what is called fibrous transformation takes place, constituting his second stage, or that of muscular retraction properly so called. Restricted to the explanation of some deformities, this theory seems to be justified by the due interpretation of facts; but it cannot be generalized without overlooking the import of other etiological circumstances. There are cases in which the deformity is due, not to muscular retraction, but to a true paralysis, which permits the action of those muscles to predominate, the motor power of which has been preserved. The doetrine of the influence of the pressure exerted upon the foetus by the uterus in the production of deformities, admitted by Hippocrates, had become forgotten when M. Martin revived it in 1836. He regards club-foot as produced by such compression brought into action by reason of the paucity of the liq. amnii—a doctrine evidently only applicable to a limited number of cases. M. Robert cannot agree with Cruveilheir in his explanation of the origin of such deformities by the compression exerted by certain parts of the foetus on other parts of its own frame.
Diagnosis.—In a given deformity we have first to determine whether it be congenital, and next to establish the anatomical condition of the intra- and extra-articular elements. It is only when these points are determined, that we can declare our prognosis and establish our treatment.
1. The determination of the congenital nature of the deformity is arrived at, from the consideration of various circumstances—viz., (a.) Its Age. Easy as it is shortly after birth to determine this, it becomes more and more difficult as we depart from this point; both because the characters of the congenital nature of the affection become modified, and those which at first marked a deformity accidentally produced become lost. In certain cases, it is almost impossible to determine in an adult or old person, whether a certain deformity dates from intra-uterine life, or early infancy. Some traumatio lesion's are, however, hardly ever met with in early life : and thus in a child presenting a luxation of the hip, we only hesitate in determining whether this is congenital, or the product of hip-joint disease, this last affection usually leaving more or less permanent traces.—(bj History. If several members of the same family present the deformity, or even different anomalies, we have the strongest presumption of its congenital nature. The personal history of the patient himself is usually defective. A strong disposition prevails to conceal the original character of an infirmity, and to refer it to subsequent accidental causes ; and when the deformity is old, and the indication false, error is often unavoidable, (c.) Number. Congenital deformities have a great tendency to appear in homological joints. In the majority of cases, when two club-feet or a double luxation of the femur exist, the affection is congenital. In rare cases the convulsive diseases of the young may give rise to these multiple deformities. Although this multiple character is a strong presumption of their being congenital, we cannot conclude inversely, that when the deformity is single it is rarely congenital, as facts would contradict the assertion, (d.) Co-existence of other anomalies of different organs. One of the most, convincing proofs of the congenital character of the deformity, is its coincidence with intra-ntenne disease and foetal anomalies. Thus the congenital character of a single club-foot was at once determined in a young man, fifteen years of age, by the co-existence of a slight spina bifida. In various of the cases quoted in the course of this work, deformities have been found in individuals who have presented shortening or junction of the phalanges, absence of bones, imperforate rectum, &c. (e.) Relative frequency and seat of the affection. Congenital deformities are met with in much greater frequency in some joints than in others. Club-foot is met with more frequently than the deformities of all the other joints put together ; and then comes luxation of the hip-joint. Next follow luxations or deviations of the shoulder, elbow, wrist, and knee, without our being able to determine their exact relative frequency. Finally, we possess a very small number of examples of deformities of the clavicle, the fingers, and the jaw. We know how rarely spinal deviation is met with in the uterus, and how often it occurs in youth; while with regard to dislocation of the femur the reverse of this is the truth, (f.) Varieties. These are much more numerous in accidental than in congenital dislocation. Thus, there arc at least six varieties of accidental luxation of the femur, while any other than that of outward and upward, is scarcely ever observed in the congenital form. At the elbow, dislocation of the head of the radius is that which is almost alone met with. Among the varieties of club-foot, there are some which are very frequently congenital, as varus and talus, while others are more frequently acquired, as equinus and valgus, (g.) The external characters offer little aid in distinguishing a congenital from an acquired luxation. The difficulty of diagnosis in some of these cases is well illustrated by a case which occurred to M. Nelaton, which he took for one of congenital luxation of the humerus, so closely did the symptoms.resemble those described by Smith. At the autopsy it was found that no luxation at all was present, the appearances resulting from paralysis of the muscles of the shoulder and consecutive atrophy, (h.) Progress. This in congenital deformity is usually slow, and a spontaneous cure is rare, especially after the first few years of life are passed. The condition of the functions is rarely advantageously modified, but bftener deteriorated. Organic or traumatic affections capable of inducing deformity are usually more rapid in their progress ; and sometimes they are susceptible of an increasing amelioration, as is seen in unreduced traumatic luxation. Sometimes, on the other hand, the affection becomes rapidly worse, as is seen in certain spontaneous luxations, or deformities, consecutive to diseases of the joints.
2. The anatomical diagnostic marks.—The condition of both soft and hard parts differs so much, with respect to the age of the subject and individual circumstances, that it is almost impossible to foresee the anatomical changes that may be met with in particular cases. Diagnosis, too, may be rendered difficult or even impossible by various circumstances, as the small size of the bones, their being very deeply-seated, the interposition of thick masses of soft parts, &c. Exploration is thus, cateris paribus, rendered more difficult in children than in adults, in persons who are stout than in those who are thin, and in joints which are deep-seated and possessed of little mobility tnan in those which are in the opposite condition. It would lead us too far to follow M. Robert in his detailed account of the various parts composing the deformed articulation.
Prognosis.—This should be considered under three points of view, the amount of functional lesion, the accidents likely to supervene, and the chances of curability. Congenital deformities of the joints have occasionally disappeared spontaneously. Fleischmann relates a case of gibbositas which did so after six months' employment of the horizontal posture; and even very well-marked club-foot has thus got well. Laugier relates a case of a child suffering from talus, and M. Bouvier has seen recovery both in talus and varus. Lateral deviations of the knee sometimes disappear in the same manner. Such cases are, however, quite exceptional; and we may lay it down as a general rule, that congenital deformities of the joints left to themselves are persistent.
In considering the cases in which it is proper for surgery to interfere, we must bo guided by the pathological anatomy. In complete anchylosis, the bold operations •performed for the relief of the accidental anchylosis of parts supplied with all their muscles, are inadmissible. Incomplete ancyhloses are too little understood to admit of any formal opinion being given; and }IL. Robert believes that they are often really false anchyloses, dependent upon the retraction of muscles and ligaments. Diastasis, due to the incomplete development of two Bones intended to be contiguous, and the absence of the whole or part of a bone, must be considered as incurable conditions. Deviations and dislocations offer the greatest chance of cure, the nearer the period of birth they are taken in hand, when the bones are cartilaginous, the ligaments flexible, and the muscles little altered in structure; and then, if the displacement be not very considerable, we may always, with the exception of some forms of these, expect either to cure, or very notably relieve, the deformity. Articular deformities, at first easy of cure, may, however, if too long neglected, at last prove refractory to all resources. It is impossible to indicate the exact period at which such a transformation is accomplished; but it may be laid down as a general rule, that articular deformities become more speedily incurable when they are congenital, than when they have been produced after birth, the changes in the parts being more complete and more intimate. Thus, while a well-marked example of varus with sub luxation of the astragalus, is often incurable, if congenital, at twenty or twenty-two; the same deformity accidentally produced may be advantageously treated at fifty, and beyond.' In judging of the curability, we have also to take into account the dynamic condition of the muscles, as well as the extent and form of the displacement of the bones. The muscle may be in a state of retraction or paralysis. In the former condition, although in old cases it becomes atrophied, it does not, except in very rare examples, undergo fibrous transformation; and therefore, when the obstacle due to the shortening of the muscles is removed, we may expect that it will recover its function. But in the case of paralysis we have no such hope; for we may act upon the shortened antagonist, and obtain the rectification of the limb; but this will remain motionless, and being left to itself, it will gradually return to its former state. So in regard to the form and extent of the displacement. Where this is a mere deviation in the arthrodia, or a slight sub-luxation, it is almost always curable; while complete luxation, which has been slowly produced, and is attended with extensive displacement, is generally beyond our resources.
The enarthroses receive separate consideration. While congenital dislocation of the shoulder has been too rarely observed to admit of any general conclusion being drawn, \ it is much otherwise with regard to that of the hip, which engages M. Robert's attention at considerable length. In discussing the question of its curability, he considers it in reference to the obstacles presented by the anatomical changes of the parts, and the clinical proofs adduced by M. Pravaz of its having been accomplished. The former of these he believes to be quite insuperable, preventing—even supposing the reduction could be obtained—any permanent effect resulting. The cases adduced by H. Pravaz are regarded by both M. Gerdy and M. Robert, as not being, in fact, reduction of the dislocation at all; while the degree of amelioration obtained was only producible by a long and painful procedure, and proved but temporary.
rreatment.—The statements already made show the importance of early treatment; but M. Robert agrees with Dupuytren and Bouvier, that this should be either undertaken shortly after birth, or delayed until after the completion of the first dentition. In treating these cases, our object is to re-establish the normal relations of the articular surfaces, by surmounting the various resistances offered by the forms or positions of the bones, and the rigidity of the muscular and fibrous tissues. To these we oppose either the action of pressure, or traction, or surgical operations. We cannot follow M. Robert in his judicious rules for the employment of these means, which, indeed, have nothing peculiar in them. He objects to the employment of tenotomy in any other manner than as an adjuvant to orthopaedic procedures, and after these have been fully tried. In the case of several muscles suffering from retraction, he does not approve of the practice of those surgeons who recommend multiple divisions. Experience has amply shown that it often suffices to remove the resistance of the most powerful muscle or muscles, whilst the others eventually yield to orthopaedic procedures. It is the more desirable to act thus, inasmuch as these last are usually the most deep-seated, the nearest the joints, and the most difficult to reach. In cases in which orthopaedic apparatus is borne with difficulty, multiple divisions of the muscles may be required. But such cases are quite exceptional in early childhood, when the section of a small number of muscles is almost always sufficient.
1. On the Diseases of the Bladder and. Prostate Gland. By William Coulson, Surgeon to St. Mary's Hospital, <fec. Fourth Edition, revised and enlarged.—London, 1852. 8vo, pp. 485.
2. A Practical Treatise on the Diseases and Injuries of the Urinary Bladder, the Prostate Gland, and the Urethra. By S. D. Gnoss, M.D., Professor of Surgery in the University of Louisville, &c. &c.—Philadelphia, 1851. 8vo, pp. T26.
Few persons who ever read a newspaper, can fail to know that Mr. Coulson has written a book on "The Diseases of the Prostate Gland and Bladder." The announcement, for years past, has rivalled that of Courtenay on 'Strictures of the Urethra,' in the frequency with which it has met our eye in the various journals—daily, weekly, quarterly. This book has now reached a fourth edition ; partly owing to the systematic manner in which it has been advertised, partly owing to its intrinsic merits, but more than either in consequence of the remarkable deficiency in this department of our surgical literature. Dr. Gross is quite correct in asserting that all the treatises on this subject as yet published in the English language, are mere outlines, which no one has attempted to render at all worthy companions to such works as those of Lawrence on 'Hernia,' Mackenzie on the ' Diseases of the Eye,' Budd on the 'Liver,' and Curling on the ' Testis.' It has remained for an American writer to wipe away this reproach; and so completely has the task been fulfilled, that we venture to predict for Dr. Gross's treatise a permanent place in the literature of surgery, worthy to rank with the best works of the present age. Not merely is the matter good, but the getting-up of the volume is most creditable to Trans-atlantic enterprise; the paper and print would do credit to a first-rate London establishment; and the numerous wood-cuts which illustrate it, demonstrate that America is making rapid advances in this department of art. We have, indeed, unfeigned pleasure in congratulating all concerned in this publication, on the result of their labours; and experience a feeling something like what might animate a long-expectant husbandman, who, oftentimes disappointed by the produce of a favourite field, is at last agreeably surprised by a stately crop which may bear comparison with any of its former rivals. The grounds of our high appreciation of the work will be obvious as we proceed; and we doubt not that the present facilities for obtaining American books will induce many of our readers to verify our recommendation by their own perusal of it.
Professor Gross enters at great length, and with much clearness, into the anatomy of the perinaeum, bladder, prostate, and urethra; and also adds a short chapter on the urine. Mr. Coulson's sketch of the normal and abnormal states of the urine is larger and more elaborate, extending to eighty-three pages; and exhibits care and attention in its composition. We are compelled to remark, however, that the degree of attention bestowed upon the different departments of the subject bears but little relation to their relative importance; and that certain misprints of proper names—such as Lecann for Lecanu, and Pattenkofer for Pettenkofer, obtrude themselves disagreeably upon our notice. We have no inducement, however, to dwell on these introductory portions of either work; as they more properly belong to the departments of anatomy and of animal chemistrj', and are almost entirely compilations from familiar treatises.
The first chapter in the division, "Diseases of the Urinary Organs," of the work of Professor Gross, treats of malformations and imperfections of the bladder; a term which we prefer to the one used by Rokitansky and by Mr. Coulson, "Abnormities of the Bladder." Mr. Coulson's chapter, " Abnormities of the Bladder," follows after those relating to the diseases of the visous; but as the other arrangement seems the most natural, and is certainly the most convenient, we shall follow it on the present occasion.
Professor Gross considers the subject of malformations and imperfections of the bladder under the heads:—I, Absence of the Bladder ;—II. Bilobation or Multiplication of the Organ ;—III. Extrophy * or Congenital Eversion. Mr. Coulson, on the other hand, adopts no division whatever; but professing to include both congenital and acquired abnormities, he notices the sacculated bladder, an effect of disease, whilst he makes no mention of those interesting curiosities in whom the bladder has been found to be congenitally divided into different lobes or pouches. Complete absence of the bladder is very rare; butthat there is no foundation for Mr. Coulson's statement, derived apparently from Rokitansky, that such a condition "must be accompanied with imperfect development of the kidneys, absence of the urethra, and defective development of other organs," is proved by the examination of the body of Abraham Clef, the account of which Professor Gross quotes from Binninger. In that instance, the bladder was totally wanting, the urine flowing from the kidneys directly through the ureters into the urethra; and although it is not stated whether the urine was discharged involuntarily and constantly, it is evident that the inconvenience was not extreme, as the patient had managed to conceal the infirmity both from his physician and his friends. Several curious cases of congenital subdivision of the bladder into two or more compartments, are brought together by Professor Gross ; and he cites from the Philadelphia 'Medical Examiner,' for July, 1850, a case recorded by Professor Johnson, in which a child, which died when eight weeks old, was found to have a sort of supernumerary bladder, in the form of a pouch, filled with urine, arising from the lower and back part of the bladder, at the place usually occupied by the right seminal vesicle, and attached by a narrow pedicle. Exstrophy or extroversion of the bladder is, in a practical point of view, the most interesting, and, at the same time, the commonest, of the malformations of this viscus. Deficiency in the anterior wall of the bladder, always associated with corresponding deficiency in the abdominal wall, and, where the fissure is at all extensive, with separation or partial absence of the pubic bones, is a condition productive of extreme discomfort and misery. Not only does the patient suffer from the inconveniences of incontinence of urine, but also from the exposure of the vascular and sensitive surface of the protruding bladder, and from the loss of that support in progression which is afforded by the junction of the pubic bones in front. It is no wonder, then, that many propositions have been made for the purpose of relieving this distressing condition, and that operations of a very hazardous nature have been performed by surgeons at various times. For those who will not be content with the admirable apparatus devised by Mr. Earle, and described in Mr. M'Whinnie's interesting paper in the 'Medical Gazette,' there is the operation of establishing an artificial passage by seton from the bladder into the rectum. As far as we arc aware, this has only been attempted twice; once by Mr. Lloyd, of St. Bartholomew's, when it proved fatal from inducing peritonitis; and once by Mr. Simon, of St. Thomas's, when it succeeded, the patient narrowly escaping with his life.
Wounds and Injuries of the Bladder.—Solutions of continuity in the bladder, from punctured or gun-shot wounds, are almost invariably fatal by the supervention of peritontitis; but a considerable period sometimes elapses before the symptoms set in. Dr. Gross proposes in such cases to open the abdomen and sponge-out the extravasated urine; a plan which, however hazardous, would, he conceives, be preferable to leaving the patient to die from the inevitable consequences of the presence of the irritating fluid in the peritoneal cavity. In civil life, we see the bladder punctured occasionally for the relief of retention, and with such results as demonstrate that there is no great haz
* We are somewhat perplexed with this term, which we suppose to be intended to represent the Ecitrojihe, or £x$trophia (e£,' out of,' and oVpotp'i),' turning'), of M. Chaussier, who, we believe, was the inventor of it. In tho form given to it by Professor Gross, it would look as if derived from Sg,' out of,' and Tpoip*], 'nourishment;' which, we presume, is not his meaning.