to us. The patient was put under blue pill night and morning, and hydriodate of potash twice a day, and black wash and red precipitate were applied locally. An impression was made in a week, the surface of the large projecting tumor assuming a convoluted form, and in six weeks the disease was nearly cured.

V.-Diseases of the Joints.

24. M. A. Bonnet, of Lyons, has published a voluminous treatise on the subject of diseases of the joints, which has been very favorably received by a part of the French press,* but much less so by another part. It is represented as being the result of five years' assiduous labor, under the most favorable circumstances. The work is limited to organic affections of the joints; and the effects of hygienic and constitutional causes in producing these affections are more completely entered into than in any other work extant. To counteract the effects of such causes great reliance is placed on those general agents which render the individual better able to resist cold, as the employment of baths and hydrotherapeutic measures, for the purpose of re-establishing the functions of the skin, and determining the blood permanently to the external parts. The effects of diathesis are most completely investigated. New views are introduced, arising out of an examination of the anatomy of texture. Fungosities developed in the joints are shown to be formed of fibrine and serosity, and to contain small capillary vessels; plastic lymph, known to pass through successive stages of development-at first inorganic, and composed of fibrine and serum-is soon penetrated with capillary vessels, and then, in a third stage, it becomes cellular, fibrous, or cartilaginous,-in a word, organized. The fungosities referred to are plastic lymph arrived at its second stage. Sometimes local, but more frequently general morbid causes prevent the progress of nature to the further stage, or that of healthy granulation. These fungosities are truly an arrest of development-they are plastic lymph, the organization of which is arrested by an internal cause. In the articulations, as in the serous membranes, the formation of fibrous tissue is the last act of the nisus formativus, and whenever we find a fibrous layer on the articular surface of bones deprived of their cartilages, or this tissue constituting membranes, or extending in fasciculi from one articular surface to the other, we may be sure that nature has made a curative effort to complete the evolution of coagulable lymph.-Following the same train of investigation, there are three distinct orders of deposit which form in the joints. In the rheumatic diathesis, the least serious, there is a tendency to secrete organizable products-as effusion of coagulable lymph. In the scrofulous diathesis-that in which fungosities most fre quently occur there is a marked disposition to secrete products which organize incompletely. In the most unfavorable states of constitution, the tubercular, the purulent, the gouty diathesis, the deposits-pus, tubercle, uric acid-are absolutely unorganizable. The author distinguishes several varieties of the scrofulous diathesis.

Placing great reliance upon absolute rest and position in the treatment of diseased joints, M. Bonnet has determined, by repeated clinical observation and experiment on the dead body, for each articulation, what attitude is injurious and what advantageous; he appropriates for each joint those mechanical means which are best calculated to fix it in position, and to facilitate its cure; and his own practice has done much to popularize the employment of his apparatus. Subsequently he resorts to "passive motion," and gives rules for its judicious employment.

Dr. A. Guepratte has also published a long article on wounds of the articulations. It recapitulates the general principles of modern surgery in the diagnosis, prognosis, etiology, and treatment of such injuries.‡

VI.-Dislocations.

25. A case of dislocation of the tibia forwards is described in the First Volume of the "Half-yearly Abstract" (article 92). In the present Volume (article 57), will be found a second case; and Mr. Hamilton has recently recorded a similar accident. Mr. Samuel Cooper states that a dislocation of this bone forwards cannot happen without the greatest difficulty, citing as a rare occurrence, that in 1802, a case was seen

*Gaz. Méd., Juin, 1845.

Annales de la Chirurgie, Juin, 1845.

† Archives Générales, Juillet, 1845.

$ Dublin Journal, July, 1845.

at Guy's Hospital. Whether this accident occurs more frequently than is commonly believed, or whether the occurrence of three cases within so short a period, is but a remarkable coincidence, the cause in all three was in principle the same; the propulsion of the femur forwards with the weight of the body forcing its condyloid extremity downwards and backwards, while the leg was either fixed, or if in motion, the power acting at the moment when the leg and thigh assumed a right line, the body still being propelled forwards. The symptoms and appearances were similar, and they were all easily reduced. These cases will assist systematic writers in describing the accident.

M. Jacquet* is reported as holding that the effect is produced by a lever of the first order, the patella being the fulcrum, the ligaments the resistance, and the lower end of the femur, the power. We have stated our dissent from this view, but are inclined to believe with Velpeau, that the leg may be bent forwards to a very considerable extent without the ligaments being ruptured; although sometimes these will give way, when the weight of the body would slip the femur behind the tibia.

26. A dislocation of the forearm backwards, produced by a singular cause, is related by Dr. Weber. In a trial of strength, a young man supported his arm in a state of extension, at a distance from his body. His competitor was to bend the limb, which he failed to do by the gradual exercise of his muscular power, but he struck a blow in the bend of his elbow with his fist, the result of which was a luxation of the forearm backwards, which M. Langenbeck, who saw the case three weeks afterwards, failed to reduce. The editor of the "Journal de Chirurgie" is severe on the ineffectual efforts at reduction, and remarks that we are in possession of means of traction which insure better results, quoting cases of incomplete luxation backwards, reduced after the expiration of nearly four months, and a complete luxation reduced on the thirty-seventh day.

27. The reviewer of M. Bonnet's work on Diseases of the Joints, remarks that M. Bonnet and M. Malgaigne consider "la maladie que Hey a décrite sous le nom de luxation des cartilages semi-lunaires," as an incomplete luxation. If the late Mr. Hey of Leeds is referred to, we are not aware that he so designated the affection referred to. After describing the symptoms, the leg being readily bent or extended by the hands of the surgeon, with at most a degree of uneasiness to the patient, but the patient himself being unable freely to bend, or perfectly to extend the limb in walking, and being compelled "to walk with an invariable and small degree of flexion," that distinguished surgeon states his belief that the complaint may be induced " by any such alteration in the state of the joint as will prevent the condyles of the os femoris from moving truly in the hollow formed by the semilunar cartilages, and articular depressions of the tibia. An unequal tension of the lateral or cross ligaments of the joints, or some slight derangement of the semilunar cartilages, may probably be sufficient to bring on the complaint. When the disorder is the effect of contusion, it is most likely that the lateral ligament on one side of the joint may be rendered somewhat more rigid than usual; and hereby prevent that equable motion of the condyles of the os femoris, which is necessary for walking with firmness." These are Mr. Hey's own words, taken from his chapter on "Internal Derangement of the knee joint." The reviewer, while he acknowledges the high authority of the two surgeons quoted, expresses his doubt as to the possibility of a displacement of the internal condyle of the femur behind the semilunar cartilage.

28. Reduction of Dislocations.-Dr. Da Camin has thought it necessary to insist anew upon Pott's principle, too little regarded, he believes, by most surgeons; viz., hat it is not the bones but the muscles which are the greatest obstacle to reduction. The insertion of the muscles involved, is first to be looked to, and the position given to the luxated member, should be regulated by the sufferings which the extension of the limb occasions. Take for instance, a luxation of the forearm; to reduce it easily it is necessary to elevate the arm to the position by which it makes an obtuse angle with the chest, overcoming the contraction of the tendons of the biceps, and of the brachialis internus forcibly applied on the inferior extremity of the humerus.

Dr. Da Camin has readily succeeded in reducing three inveterate luxations of the humerus by a simple movement, which consists in drawing the humerus backwards

* Gaz. des Hôpitaux, May 1

Aug 1, 1845.

Annali Universali di Medicina, Dec., 1844.

† Archiv für Physiologische Heilkundie.
Archives Générales, Juillet, 1845.

by its inferior extremity; in this manner, he brings together on the one hand, the points of insertion of the biceps, while on the other hand, he separates those of the antagonist muscles. One of the cases reduced in this manner had subsisted for fortynine days, another fifty-three, and the third, 106 days.

Mr. L'Estrange, of Dublin, has described, with a woodcut,* a new apparatus for permanent and steady extension in dislocations, and Dr. Gilbert, of Pennsylvania, has recommended a plan first resorted to by Dr. Fahnestock, of Pittsburg, of employing, in the absence of pulleys, the power derived from twisted rope, for the purpose of obtaining steady and equable traction. The following is the mode of application : Place the patient and adjust the extending and counter-extending bands, as if for the pulleys; then procure a rope, such as is used for suspending clothes to dry, or a bedcord, tie the ends together, and again double it upon itself; then pass it through the extending tapes or towel, doubling the whole once more, and fasten the distal end, consisting of four loops of rope, to a window-sill, door-sill, or staple, so that the ropes are drawn moderaetly tight; finally, pass a stick through the centre of the doubled rope, dividing the strands equally by it; then, by revolving the stick, the rope being shortened, extension is produced slowly, steadily, and continuously; while the surgeon, with his hand upon the part, directs the head of the bone towards its destination, as in cases where the pulleys are used.

29. Anchylosis. From Dr. Pancoast's" Operative Surgery," we learn that Dr. Barton has suggested and performed a new operation for anchylosis of the hip, which it is believed may be found applicable to a similar condition of other joints. It consists in making a crucial incision over the trochanter major seven inches in length, and five broad, dissecting the flaps back, dividing the fascia, detaching the muscular fibres from the upper extremity of the femur, dividing the head across with a saw, and subsequently moving the lower portion from time to time on the upper, for the purpose of preventing solid reunion, and of forming an artificial joint.

{ VII.—Fractures.

The French press in particular, of the last six months, contains some very interesting matter on fractures, which, however little disposed we may be to admit the validity of all the views embraced, cannot fail to strike the British surgeon, as well deserving his consideration. Certain it is that the principles of treatment in fractures are in many instances still unsettled, and we do not believe that a strict adoption of those which are well ascertained has ever yet been carried out in actual practice.

30. In the first place we have before us some important papers on the oft-discussed subject of fracture of the neck of the femur. Mr. Bransby Cooper† follows Sir Astley in firmly maintaining that nature is opposed to the osseous reunion of such an injury, that-1. The low condition of the reparative powers at an advanced period of life.—2. The changes peculiar to the hip-joint from age.-3. The peculiarities of original structure, are inseparable impediments to union. Mr. Cooper explains various alterations in structure, and refers to the absence of those tissues which are connected with the bones, and which perform so important an office in their reparation, particularly in the processes preparatory to ossification, as special obstacles. In the process of reparation of fracture, external to the capsule, the bony union takes place to the very edge of the attachment of the synovial membrane, and no further, a proof that it is ordained by nature that it shall not take place within the capsule. The necks of old femora having lost their powers of generating phosphate of lime is another insuperable obstacle.

With these views, Mr. Cooper maintains that no mode of treatment can lead to bony union, that every kind of apparatus is alike useless, and that it is highly injurious to patients to attempt it. Views similar to this are for the most part acted upon by British surgeons, yet it is admitted that bony union sometimes takes place, and even Sir A. Cooper had satisfied himself of the fact. On the other side of this great question, we find Chelius, a high authority among the Germans, asserting that the reason bony union has hitherto in England been seldom observed, may depend on the very careless treatment of fractures known to be within the capsular ligament; and that the condi

* Dublin Med. Press, July 23, p. 60.

System of Surgery, translated by South, p. 567.

† Guy's Hospital Reports, Oct., 1845.

>

tion of the head of the bone has nothing to do with it, but rather the difficulty of keeping the fractured ends for a proper time in sufficient contact. Again, we have before us a recent article by a French surgeon, M. Guerin,* whose views are briefly as follows:

After remarking that, among the fractures which generally unite by ligamentous tissue is that of the neck of the thigh-bone within the capsule, and that no doubt now exists of the possibility of osseous union in this situation, M. Guerin adopts Bichat's reasoning, that the organization of the femur is nearly the same at its neck as in its body, and records experiments to confirm it, and to prove the vitality of the head of the bone after its separation. Injected fluid was easily made to pass from the ileum through the round ligament to the head of the femur. Many reasons also are given to prove that the vitality of the neck of the femur is sufficient for the formation of callus. Instances are quoted in which, after non-consolidated fractures, the round ligament was found to be extremely vascular, and its vessels greatly dilated. M. Guerin believes that the true cause which prevents osseous union is the mobility of the fragments. Neither the inclined plane, Desault's splint, nor any of the methods employed for the cure of these accidents, are sufficient to prevent motion; and if in spite of this mobility, union by fibrous tissues still takes place, it shows a powerful tendency to bony union, since the fragments are continually sliding upon each other,—as much so as when the surgeon attempts to form an artificial joint. It is no argument that this displacement of the fragments has no effect upon the union of fractures without the fibrous capsule, which are mostly oblique, since intracapsular fractures are nearly transverse. Contrary to the prevailing opinion, the author believes that bony union might generally be obtained, by preventing the motions of the pelvis, to effect which M. Bonnet's apparatus is completely effectual.

This apparatus consists in a solid half-cylinder (gouttière) which contains the two posterior thirds of the fractured limb, and the two posterior thirds of the pelvis and abdomen. Its framework is a bar of iron, solid behind, thinner at its sides, which are sufficiently supple to be bent towards or from the axis of the box. This framework is well covered with horsehair; on its sides, above the great trochanter, and on a level with the knees, are bracelets from which cords proceed which pass through a hook at the head of the bed. The patient, placed in this apparatus, which has a large opening on a level with the anus, can easily raise his whole body horizontally above his bed-he has only to draw the cord for this purpose. In every case the body is moved as a whole, the vertebral column has no motion on the pelvis, nor the pelvis on the thigh; accordingly, there is no tendency to displace the fragments. To prevent rotation outwards the extremities of the gouttière rise up on each side of the foot to the top of the great toe. Continued extension is made by means of a weight which moves on a pulley fixed to the apparatus. The lateral motions of the trunk are confined by the sides of the apparatus, which reach nearly to the armpits.

We place before our readers these diametrically opposed opinions, and can only say that, with the facilities afforded by our hospital appointments, we shall feel surprised if a serious question of fact, such as this is, cannot be definitely settled by the statistics of experience.

31. Fractures of the Clavicle.-M. Guerin's memoirt embraces not only the treatment of fractures of the neck of the femur, but also of other fractures which are generally very imperfectly united. His principal object is to prove that if these fractures unite only by the medium of fibrous tissues, or by the formation of an irregular and deformed callus, such a result is produced by a radical error in the treatment. Some deformity almost always follows fracture of the clavicle. The author approves of Desault's principle of using the humerus as a lever, with a pad in the armpit as a fulcrum, for the purpose of pushing the scapula backwards, upwards, and outwards, in order to bring the depressed external extremity upon a level with the internal one of the broken bone. But he states that neither Desault nor any of the surgeons before or since his time have dreamt of one important indication, viz:-" to prevent the mobi lity of the internal fragment." M. Guerin proves by experiment, that on the motion of the arm on the sound side the ends of the broken bone ride over each other, and particularly that when the arm on the sound side is carried backwards the sternal fragment slides from above downwards. And, also, that when a person with a broken

* Archives Gén., Juin, 1845.

† Archives Gén., Mai, 1845

clavicle turns his face to the sound side, both arms hanging down, the internal fragment of the bone is carried upward by the contraction of the sterno-mastoideus muscle, and that even when the arm is fixed and bandaged by the ordinary methods a crepitus is produced by these motions. The effect on the internal fragment is greater in proportion as the seat of the fracture approaches the insertion of the above-named muscle. The indications which the surgeon has to fulfil, in order to obtain an exact and regular consolidation, are accordingly three. 1. The scapula should be directed upwards, backwards, and outwards, and fixed with an immovable bandage. 2. The arm on the sound side should be fixed to the chest so as to prevent its motion. 3. The action of the sterno-mastoid muscle should be opposed by keeping the face directed towards the fracture by bandages.

M. Guerin does not dispute the inconveniences which must attend the fulfilment of all these indications, particularly if persisted in for a month. He remarks that experience must decide, but that possibly, owing to the great quantity of callus thrown out, the motion of the head may be allowed after a few days, without injury. The reviewer of this paper in the "Gazette Médicale,' admits the correctness of M. Guerin's principles, but thinks they will not be put into practice, since the incon veniences resulting from a badly-united clavicle are not very important. Upon this, however, it may be remarked that the deformity resulting from such an accident is not always regarded so lightly, especially when the subject is a female. The same cause is in operation to prevent the bony union of the patella and olecranon, the superior fragment not being invariably kept in contact with the inferior one by the various means employed.

32. In Fractures of the Olecranon, surgeons have been too much occupied with one thing only-the position of the arm and forearm. But the indication of diminishing or preventing the influence of the triceps muscle, in drawing the superior fragment upwards, has either been overlooked or imperfectly accomplished. To effect this M. Guerin recommends three wooden splints, corresponding to each portion of the triceps muscle, to be fixed by means of a starched bandage. The indication might be fulfilled by moistened pasteboard, which, being moulded to the surface, would not compress the osseous projections too forcibly. If wooden splints are used, they need not descend so far as the olecranon. The limb should be extended, and the fragments maintained in contact with the usual bandage. This method has not been put into practice, but the author considers it rational. The action of the triceps is the true obstacle to bony union. A case of fracture of the olecranon, in which M. Blandin kept the forearm in a state of flexion, is recorded. He considers, in this accident, that anchylosis is most to be dreaded, and that if this should be the result, the best position for the limb is semiflexion. He has tried both flexion and extension, and admits there are circumstances in favor of each plan. The opinion that the former has a greater tendency to prevent bony union is without foundation. M. Blandin makes the curious remark, that a certain degree of separation of the two fragments may present itself at the surface, after the termination of the case, and the union may at the same time be immediate and complete below. The bone may be completely united in the deeper parts. This fact was observed after death, in an individual who a short time previously had fractured the olecranon.

33. The imperfection previously described is met with, according to M. Guerin, in the treatment of Fractures of the Patella. In this case, as in that of the olecranon, an X bandage fails to keep the divided fragments in apposition. Boyer placed the leg in a box, to the sides of which straps were fixed, which confined the superior and inferior fragments previously brought into apposition. The box has the advantage of keeping the limb extended, and the straps do not compress the flexor tendons in a troublesome degree, but the triceps maintains its power, and opposes the union of the fragments. By means of a double (érigne) crochet, M. Malgaigne obtains bony union of the patella, whatever may be the position of the fractured parts of the bone. With the double crotchet he grapples the tendon and the ligament of the knee-pan, and the two parts are brought together by two steel plates, and fixed by a compressing screw. As per fect union is obtained by this means as in the middle of the long bones. Many practitioners have witnessed the favorable results of the practice. If this plan is not adopted, a bandage may be resorted to for the purpose of compressing the extensor muscles of

* Aug. 9.

† Gaz. des Hôpitaux, July 12, 1845.