long at the back of the joint, he dissected back the integuments on either side, until the joint was fully exposed. During this dissection no ulnar nerve could be discovered. He then applied the saw to the olecranon at its junction with the shaft of the ulna, and having sawn through the bone in that position, the saw was again applied to the humerus just above the condyles, and the piece of bone intervening between the two cuts removed. At this stage of the proceedings a large quantity of pus spirted out with great force from the neighborhood of the joint. Some diseased tissues, implicated in the abscess, were then dissected off. No ligatures were required, and the edges of the wound were brought together by two stitches.

30th. The patient having gone on very well during the intervening days, the arm was placed in Mr. Heath's splint (before described), and fixed once or twice upon the humerus. The bones were kept well apart from one another; but after a time the arm and hand became rather swollen, and

On July 3d the splint was taken off, and the arm placed on a straight splint. On the 7th, Heath's splint was again applied and the arm now and then flexed, the extension caused by the splint much lessening the pain of that operation. The wound assumed a healthy appearance, and the patient was in a very satisfactory state.

On the 20th, the wound was reported as looking very healthy," and at each dressing the arm was flexed and extended, not much pain being inflicted.

At the beginning of August the side splints were taken off, and a straight splint in front of the joint was substituted. The wound now scarcely discharged at all. The arm was flexed, extended, and rotated at each dressing. By the middle of the month the patient had regained some power of motion in the fingers and wrist.

On August 25th the splint was left off, and the arm was supported in a sling.

About the second week in September, when she left the hospital, the wound had almost closed. There was plenty of motion in the joint, and she could raise the hand to the head.

CASE 3.-Wm. R- æt. 26, a florid robust looking man, was admitted on August 19th, 1857, with disease of the right elbow-joint. The patient states that up to about six years ago he has always enjoyed good health. About that time he contracted syphilis, for which he was mercurialized. This was followed by an eruption, accompanied by pain in the limbs and joints, more especially the right elbow and knee. Shortly after he found that his right elbow was swollen and painful. This in about three months yielded to treatment, but he was never after able to place the limb in a perfectly straight position, nor could he flex it sufficiently to touch the shoulder without great pain. In May last he had a return of the pain and swelling in the joint. This continued unabated up to about five weeks ago, when an abscess formed in the joint.

On admission, the swelling was considerable about the elbow, and the contour of the joint entirely lost. The forearm was slightly flexed on the upper arm, and on pressing the forearm upwards a peculiarly elastic feeling was given,

Aug. 20th.-An incision was made midway between the condyles of the humerus, and a considerable amount of offensive matter discharged itself. A probe introduced through the wound passes readily into the joint.

The ulnar

30th. The patient being placed under the influence of chloroform, Mr. Fergusson proceeded to excise the joint. As in the other cases, this was accomplished by making the vertical incision at the back of the joint. nerve being carefully hooked back and secured from injury, the humerus was sawn through just above the condyles, and the olecranon and the head of the radius were also removed. Much bleeding occurred during the operation.

Sept. 1st.--Heath's splint was put on, and sufficient extension made with it to separate the ends of the bones. The wound looks healthy, and the patient suffers little pain.

7th.-The arm was bent for the first time, and caused very little pain. 10th. The splint was removed to allow the swelling to decrease.

20th. The splint was left off entirely, as it was thought that the effect it

had had in keeping the bones asunder was sufficient to secure perfect motion in the joint. The patient can flex the arm a little himself, and with slight assistance can raise his hand to his mouth. The wound is looking very healthy, having closed up to a great extent in a surprisingly short period of time. The patient's health is much improved, and a most favorable result is expected.

ART. 112.-Division of the Tendon of the Triceps in old Dislocation of the Elbow. By Mr. FERGUSSON, Surgeon to King's College Hospital.

(Lancet, Feb. 2, 1858.)

The following remarks are from the "Mirror of the Practice of Medicine and Surgery in London:"

A boy, whose left elbow had been dislocated with both bones backwards, since October last, was brought into the theatre of King's College Hospital on the 16th of January, the arm being in a semi-flexed position. When under the influence of chloroform, Mr. Fergusson applied forcible flexion, so as to break up any adhesions which might be present, and thus allow of a movable joint. This, however, could not be satisfactorily accomplished until the tendon of the triceps cubiti muscle was divided by subcutaneous incision, where it is inserted into the olecranon process of the ulna. When this was completed, complete flexion was obtained, and the arm was for the present bandaged in that position. After a while motion will be used, and, no doubt, a good useful arm will result from this treatment. Mr. Fergusson stated that a short time ago he treated another case in a similar manner. A gentleman returned from abroad with his elbow dislocated, and his arm in a straight position, the accident having ensued eleven months before. As the arm was perfectly useless in that position, he was most anxious to have something done. Mr. Fergusson, therefore, resolved to try forcible flexion, which did not succeed until the point of resistance was overcome, and that was the subcutaneous division of the insertion of the triceps muscle, when, as in the case of the boy, the most perfect flexion was gained. This gentleman made a good recovery, with a useful arm. Had the operator not succeeded in remedying the awkward position of the arm, he was quite prepared to excise the joint, which no doubt would have given an equally useful arm.

(D) CONCERNING THE INFERIOR EXTREMITY.

ART. 113.-Of Pain and Weariness in the Lower Limbs of Persons having Flat Feet. By Mr. PAGET, F. R. S.

(Medical Times and Gazette, March 13, 1858.)

"Among the numerous instances of this that I have seen in the out-patients' room, I do not remember one in which the patient was aware of his deformity, or did not give an account of himself that was calculated to mislead. The common story is, that he has heavy aching pain in one or both of his ankles, or in his feet or soles; pains extending up the limbs, with weariness, and inability to go through his day's work. And all these or more he ascribes to cold or to some injury; he has no suspicion of deformity, but his feet are flat. The soles are, perhaps, not everted; there may be no true valgus, but the feet look elongated, flat, and low, without insteps; the heels are too little prominent, the plantar arches sunken, the ankles thick, the astragalus, navicular, and inner coneiform bones are below their right level. The pains complained of are those of the muscles and tendons, which are habitually overworked, in the task of keeping the body erect, when its proper bearings on its supports are disturbed; and the like pains may exist in any case in which the foot is habitually used awkwardly.

"The treatment of such cases with orthopedic apparatus is generally sufficient for the relief of the pain; rarely so for the cure of the deformity. With such apparatus, and often without it, as the patients (who are generally

between 15 and 20) grow older, the muscles and other structures become accustomed and more adapted to their undue action, and cease to be painful. Many men above 30 who are flat-footed make no complaint of it. The most flat-footed I have seen could walk thirty miles in the day without considerable fatigue.

"In all these cases the pain is probably due to the impairment of composition, which ensues in the muscles during exercise, becoming, at last, greater than can be repaired in their ordinary repose, or when the general health is enfeebled. Pain of a much severer kind, but probably due to a similar condition of unrepaired change of composition, is sometimes consequent on excessive work continued for a comparatively short time.

"A feeble lad, 17 years old, complained of pain in his right arm, especially in the lower part of the biceps, and in the flexors in the forearm. He held his arm bent at the elbow, and nearly straight at the wrist, and he said he could not move it; but he could do so, though feebly and slowly, as if the muscles, though not cramped, were stiff. All the joints could be moved in their full range, smoothly, and without pain. There was no swelling anywhere, but the biceps and flexor muscles felt unequally firm, and some parts of them felt nearly hard, like muscles with the cramp. There were no signs of constitutional disorder, and the only cause that could be assigned for his pain and other trouble was that he had been working for five months as a smith, hammering for ten hours a day. Rest alone, I believe, cured him.

"Sometimes a muscle after excessive exercise passes into a state of nearly fixed contraction, and abides long therein. Wry-neck may thus follow a great exertion of the muscles of the neck; and I have seen an elbow-joint stiff and motionless through rigidity of muscles ensuing in or quickly following a great effort. These cases are to be distinguished from those of rheumatism, which, in persons disposed to it, is often localized in a muscle shortly after it has been subjected to a too wide or violent action. And it would be very interesting to study the similarities between the stiffness and loss of power in exhausted muscles and the rigor mortis; they are much greater, I believe, than would be generally suspected."

ART. 114.-Excessive Dilatation of the Bloodvessels of the right inferior extremity. By Mr. ADAMS, Surgeon to the London Hospital.

(Lancet, Jan. 2, 1858.)

This unique case is essentially one of congenital dilatation of the arteries and veins of the right lower limb, accompanied by an aneurism by anastomos sis in the interior of the os calcis. Death was brought about by the rupture of the aneurism.

Case.-Mr. L, æt. 30, was sent to me from Canada, on the 4th of August, 1856, for my opinion on his case, by Dr. Lister. He told me that he was subject to a bleeding ulcer near the outer ankle, and that this was accompanied by an enormous dilatation of the arteries and veins. From his own account, it appeared that the disease was congenital, that it had gradually increased, and that only lately it had attained its extraordinary development. He had been subject for many years to occasional attacks of hemorrhage, which he could himself readily control by pressure. He was a healthy-looking man, with no evidence of internal disease, except that his heart beat more forcibly than natural; but this might be attributed to excitement.

The following were the appearances of the limb: The thigh exceeded the other in bulk by one-third. The vena saphena in the thigh was swollen to the size of a man's forefinger, and was distorted in various directions. At the back part of the thigh, there was a pedunculated tumor connected with the vein (evidently a thrombus,) from which the blood could be readily squeezed out. The leg was much attenuated, from diminution in size of its muscles; but the veins were excessively dilated, especially about the calf and ankle. The whole surface of the foot was covered by a mass of plexiform veins. When the muscles of the calf were grasped, the mass gave the idea of

a sponge from which fluid was pressed out. The arteries were of extraordinary size, and could be felt pulsating over almost the entire limb. The impulse at the groin, along the whole course of the femoral artery, and in the popliteal space, was enormous. A distinct, oblong, aneurismal dilatation was felt in the popliteal space to the extent of three inches. Below this, the posterior tibial artery could be distinctly traced along the back of the tibia. On removing the bandage with which the leg was enveloped, there was an ulcer or excavation a little behind and below the outer malleolus. From this source, repeated attacks of arterial hemorrhage had occurred, which were always arrested by pressure. It was covered with an ointment, and I did not remove the dressing, as the patient was fearful of hemorrhage. I therefore carefully strapped the foot and ankle, and replaced the bandage.

August 6th. I was called to him this morning, in consequence of a smart attack of arterial hemorrhage, which had stopped when I reached his lodgings, but I thought it my duty to examine the source of hemorrhage. I found an irregular, excavated ulcer, larger than a shilling, and filled with a tough coagulum, from beneath which arterial blood was oozing. I had scarcely touched the coagulum, when an immense jet of arterial blood rushed up with a whizzing sound to the height of a foot. I instantly pushed my thumb into the wound, and found a deep hollow extending into a bone. I immediately pushed a piece of sponge into the opening, and sent for the assistance of Mr. Coulson and Mr. Ward, being determined to amputate the limb below the knee. However, the patient would not listen to the proposal, and was satisfied from his former experience, that it could be arrested by pressure as before. We therefore applied firm pressure by strapping and bandaging, and the hemorrhage stopped, although not immediately. I saw him the same evening, when he said he was comfortable, and merely requested that the bandage might be slightly loosened. He had a dose of laudanum, and this was

repeated in the course of the day.

On the next morning, I advised his removal to the London Hospital, as his lodgings were exceedingly ill-adapted to any operative procedure which might be deemed advisable. To this he consented.

8th. I was sent for to him early this morning, and found that hemorrhage had recurred two hours before my arrival, but that it had been stopped by pressure. However, as the plaster and bandages seemed loosened by the effused blood, I removed them, and found that the skin had sloughed to a great extent, that the tendons were laid bare, and that blood was oozing still from many sources; and he was so exceedingly depressed on my arrival that all operation was now out of the question. I ordered as much brandy as could be got down, but he sank half an hour after my visit. I had previously arrested the bleeding by dry lint and bandage to the wound; and had applied the clamp-tourniquet to the inguinal and an ordinary tourniquet to the popliteal artery.

I examined the limb the same afternoon. The arteries from the external iliac were dilated to at least three times the natural size. In the groin there were two aneurismal dilatations of no great size, and connected with the popliteal artery there was an oblong aneurism three inches and a half in length, and an inch and a half in diameter. The coats of the arteries were for the most part exceedingly thin, but here and there they presented patches of atheromatous deposit, so that their area was very irregular. The veins were enormously enlarged; indeed, the deeper-seated veins accompanying the posterior tibial and fibular arteries were so large as to give the idea of large venous sinuses rather than veins; coagula as large as pullets' eggs could be readily drawn from them, and they were so firmly adherent to their accompanying arteries and the periosteum of the bones that it was impossible to detach them. The outer surface of the os calcis, now deprived of its periosteum, was perforated by numerous large openings, whence the hemorrhage had occurred; the interior of the bone was filled with coagulum and the débris of blood vessels, and on maceration its cancelli were found remarkably attenuated, and almost wholly gone. The astragalus had begun to exhibit marks of disease, as the periosteum was gone in that space where the interosseous lig

PART XXVII.

11

ament connects it with the os calcis. No other part was examined, as we were restricted in the opportunity of any further examination.

ART. 115.-The Subcutaneous Operation on Varicose Veins. By Mr. HENRY LEE, Surgeon to King's College Hospital.

(British Med. Journal, Jan. 9, 1858.)

When blood is effused into the cellular tissue in the living body, it undergoes changes varying in different cases. Sometimes it is simply absorbed, leaving the surrounding parts as they were before; sometimes the fibrin becomes separated from the more fluid parts of the blood, and remains after these are removed. Again, the effused blood may remain contained in a kind of sac, of a dark grumous color, for weeks or months; or finally, it may undergo a process analogous to that of suppuration, and be discharged, more or less deprived of its coloring matter, as from an abscess. Blood that remains for any lengthened period stagnant in veins undergoes somewhat similar changes. It may be deprived of its serum, and its more solid parts may remain, obstructing the veins for almost an unlimited period, or it may become dark and grumous, undergoing a kind of slow decomposition; or again, in the fibrin previously separated from the other constituents of the blood, cell-development may take place, and an abscess will form in the vein.

In the various operations which have from time to time been practised for the obliteration of varicose veins, the effused and stagnant blood has occasionally either undergone a kind of decomposition, or has become involved in an abscess; and when the products of these changes have become mixed with the blood, it is now well known with what fatal certainty their presence is manifested. The occasional, although rare occurrence of the symptoms, now recog nized as those of blood-poisoning, after operations on the veins, has led surgeons from time to time to seek for modes of operating which should be free from the dangers previously experienced.

In 1815, Sir Benj. Brodie published a paper in the "Medico-Chirurgical Transactions," in which he advocated the subcutaneous division of varicose veins. In that paper, the advantages of the subcutaneous mode of operating are clearly pointed out. (A description here followed of Sir B. Brodie's mode of performing the operation.) In this mode of operating, no adequate provision is made against hemorrhage from the divided vessel on the one hand, nor against the absorption through the open mouth of the vein of the products of the effused or stagnant blood on the other. If a vein be simply divided, no one can tell exactly how much blood will be effused; and, if effused in quantity, the changes above mentioned will occasionally take place. These changes may occur either in the blood outside the vein, or in the stagnant blood still within the vessel, or the action may be communicated from one of these to the other. The product of these changes may be localized by the unassisted powers of nature; the vein may be closed, so that no absorption through its canal can take place. In like manner, an artery, when divided, may spontaneously cease to bleed; but nevertheless surgeons are not fond of trusting to these unassisted powers of nature. In one case, as in the other, that which may take place from natural causes may be with tolerable certainty effected by artificial means. The vein, like the artery, may be safely and efficiently closed. If this be carefully done before an enlarged vein is divided, the effusion of blood is in the first instance prevented, and there is proportionately less risk of any of the morbid changes which have been referred to; and secondly, even should such changes take place, the products of such changes are prevented from entering the circulation through the wounded vein.

Such were the considerations which induced Mr. Lee in the year 1853 to try a new mode of performing the operation of subcutaneous division of varicose veins. The plan then adopted was to place a needle under the vein both above and below the part to be divided. A ligature was then placed over the needle in each situation, and allowed to remain for a couple of days. At the expiration of this time the blood was usually coagulated in the vein, which would be felt as a round soft cord on either side of and between the needles. The vein