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utility. Still, the author refers to two cases of fracture of both bones of the leg, in which, in spite of every care, an angular displacement occurred; while certain cases of fracture of the fibula, whatever apparatus may be employed, and whatever care taken, are followed by a little abduction of the foot and slight elevation of its external border. (2) Displacements according to circumference are rarely irreducible. Still this is the case with a considerable number of fractures of the neck of the femur, with permanent penetration of the upper into the lower fragment, rotation outwards not being corrigible by other than imprudent attempts. M. Gosselin has likewise met with three cases of fracture of the leg in which irreducible displacement in the circumference has occurred. (3) Of the displacements which take place according to thickness, some are corrected easily and are not reproduced, others are reproduced again, until prevented by diffused pressure; and others, again, are irreducible, do what we will. In several instances the author has been unable, in fracture of the leg, to place, even with the aid of chloroform, an upper or lower fragment which projected beyond the other. This he attributes to the indentation of the fragments, the teeth not fitting into each other during the efforts at reduction, except as a mere matter of chance. (4) In considering the displacement according to length, besides the part played by muscular action, account has not been taken of the considerable crushing of the bone which results from the reciprocal pressure of the fragments. Here there will be shortening of the bone with impossibility of restoring it, the shortening even becoming augmented by subsequent absorption.

4. Fractures near Joints. The frequency of fractures near joints, and the great liability to them of subjects aged more than fifty years, has been long known; but M. Vollemier, by introducing the term penetration in relation to fractures of the lower end of the radius, MM. Hervey de Chegoin and Robert, by demonstrating such penetration in fractures of the neck of the femur, and M. Trélat, by calling attention to intracondylian fractures of the lower end of the femur, have given quite a new impulse to the study of this description of fractures. But still there are wanting a generalization of these new facts and clinical deductions. In fact, these various fractures resemble each other in their mechanism and their lesions. (1) The fracture of the extremity of a long bone may take the transverse direction, and be unaccompanied by any crushing of the spongy tissue. This is the only fracture, indeed, recognised prior to Vollemier's investigations, but it is the most rare. (2) More frequently one of the fragments becomes so forced into the substance of the other that the penetration remains permanent, the spongy substance of the penetrated fragment being completely crushed. If the two fragments be separated, an accidental cavity will be seen to be hollowed out by the penetrating one, the latter usually presenting an irregular or toothed surface, which enters into such cavity. This variety is especially met with at the cervix femoris, and at the lower end of the radius. (3) In other cases, one of the fragments presents the depression and crushing of the spongy tissue, but the other is not lodged in this depression, and is removed from it some millimetres in front or behind -penetration having in fact taken place at the time of the accident, but not being maintained. This disposition is especially met with in the radius, and is more rare than the preceding or subsequent variety. (4) One of the fragments, usually the shorter, may be comminutively fractured-the penetration being more forcible and deeper than in the preceding cases. variety is observed in stelliform fracture of the radius, in fracture of the neck of the femur when the great trochanter is fractured at the same time, and in fracture of the lower end of the femur, when there are at the same time intraand supra condylian fracture. To these cases a proper clinical import has not been given, and fractures are described just as formerly. But how are we to reduce fractures when their fragments are so solidly penetrated and ingrained


as to be scarcely separable, even after death; or when one of the fragments has become shortened by crushing or by comminution? It is evident that surgery can do nothing here, and that the limb must remain enlarged and shortened, and that the action of the joint must be impaired.

5. Therapeutical conclusions.-It is not the author's object to deter from attempts at reduction of fractures. These, he admits, must be made, and in case of failure repeated. But when complete adaptation cannot be thus obtained, and the failure is explicable on one of the grounds mentioned, attempts should not be multiplied, or complicated and expensive apparatus resorted to. In the author's opinion, a careful and attentive surgeon may obtain with the most simple appliances all possible results. The consecutive deformities or imperfections may be inevitable; and it is an illusion to suppose that in all cases they may be completely prevented.



Physician to the Royal Maternity Charity, Assistant Obstetric Physician to the London Hospital, &c.


Appearances of the Yearly Ripening of Ova in Woman. By Dr. MATTEI. (Gaz. des Hôpitaux, No. 22, 1859.)

Dr. Mattei regards the theory of the monthly maturation of ova concurrently with menstruation as erroneous, and believes that for each ovary only one annual ripening takes place. The months of January, February, March, and April are especially favourable for this maturation. The appearances of this condition come on at times very gently, at others very painfully. The general appearances are, alterations of the voice, sleeplessness, at times neuralgias, prostration, vomiting, frequently palpitation, cough, hoarseness, without material change in the breasts. As focal symptoms there are, sensation of weight or pain in the abdomen, from the sacrum to the thighs, and especially pains in that side of the pelvis on which the lymphatic glands are swollen and tender; there is also heat and excitement of the external genitals. The menstruation is disturbed; it is seldom rendered more profuse, most frequently more scanty, coming on earlier, and attended with nausea. At times leucorrhoea, diarrhoea, dysuria, sympathetic symptoms in the breasts; the excitation of the ovarian region causes pains, nausea, even hysterical cramps; hematocele, peritonitis, and phlegmon may occur. According to the individual, these symptoms may last for four, twelve, or twenty-eight days, and disappear altogether, or pass into symptoms of pregnancy or false conception. The interval between the ripening of the ova in the two ovaries is variable. The minimum observed by the author was four days, the maximum, five months. Dr. Mattei further says that this yearly ripening mostly ceases at the same epoch as the germination of plants and the rut of animals.


On the Extirpation of Interstitial Fibroid Tumours of the Uterus. By
B. LANGENBECK. (Deutsche Klinik, 1. 1859.)

Langenbeck refers to the little success attending the medicinal treatment of uterine fibroids; and distinguishing them into sub-mucous, sub-peritoneal, and interstitial, says that the sub-peritoneal are not favourable for removal by operation, on account of the danger of peritonitis. Including three cases of

removal by the author, there are twelve cases in which the operation has been performed; in seven, cure ensued. The following is a condensation of Langenbeck's cases:

1. T—, aged thirty-five, mother of two children, had suffered much the last two years from metrorrhagia. After three days' pains a tumour of the size of a child's head had descended into the vagina, and at last beyond this. It was taken for the head. The pains weakened, and the patient collapsed. Langenbeck being called, made an incision through the entire tumour exposed beyond the vulva, and there appeared under the layers of the os uteri a yellowish-white fibrous mass, which could be separated easily, partly with the fingers, partly with the scissors. Hæmorrhage slight. The dead child was immediately extracted. The patient died in the following night.

2. E, aged thirty-seven, had suffered from profuse metrorrhagia. In November, 1856, Langenbeck found her very anæmic. The os uteri was high up, open, with a swelling the size of a hen's egg in the posterior wall. The anterior wall was thinned, the posterior one thickened. After attempts had been made during eight days to expand the os, extirpation of the firmly-fibrous tumour was carried out. The bleeding was inconsiderable. Two months later normal menstruation returned. Recovery was permanent.

3. S, aged thirty-five; after two normal labours and one abortion, metrorrhagia set in, and produced a high degree of anæmia and weakness. Langenbeck found a tumour the size of the fist in the fundus uteri ; the hinder lip of the os uteri was doubled in size; this enlargement extended into the posterior cervical wall. The anterior lip was thinned, the orifice open; and through this the finger felt a swelling the size of a goose's egg, projecting an inch and a half into the rectum. On March 24th, 1855, extirpation was undertaken. The operation was difficult and of long duration, because the tumour was nowhere distinctly bounded, and was very resisting. The hemorrhage was not considerable. Free suppuration from the uterus ensued; and in August, 1858, the cure was established.


1. On the Causes of the Spiral Direction of the Umbilical Vessels, and the Convolutions of the Cord in the Human Fœtus. By JOHN SIMPSON. (Edin. Med. Journ., July, 1857.)

2. On the Transmigration of the Orum as a Cause of Tubal Gestation. By Professor KUSSMAUL. (Verhandl. d. Naturl. Med. Ver. zu Heidelberg, Band iv. p. 102, 1858; and Schmidt's Jahrb., No. 5, 1859.)

Mr. John Simpson gives a very interesting physiological account of the forces producing the spiral direction of the umbilical vessels. Our limits impose upon us the necessity of devoting the greater portion of our space to extracts from the more inaccessible foreign journals, and constantly compel us to pass over or to notice with brevity the contributions of our brethren at home. So in this instance we must forbear to trace the train of facts and arguments advanced by the author. The spiral or twist of the umbilical cord is known to be most frequently from left to right. Velpeau considered this to be caused by rotations imparted to the fœtus in the liquor amnii by the movements of its limbs. Schroeder van der Kolk supposes that the greater pressure of the blood in the arteries than in the vein causes a recoil, which reacting on the pubes of the floating embryo, causes it to turn on one side or the other according as they are placed on the left or right side of the umbilical vein in the annulus umbilicalis. The author adduces evidence to show that the direction of the twist is dependent on the structure and distribution of the arterial system of the fœtus, and the action of the heart upon the fluid within

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its tubes. Until after the eighth or tenth week there is no twist in the cord. At and after this period it will be found that the aorta is parallel with the spinal column in its left side in the dorsal region; then tending, in the lower part of its course towards the mesial line, to divide into the right and left iliac vessels on the bodies of the lumbar vertebræ, thus presenting a curve whose concavity looks forward and to the right. From this crossing of the aorta from the left side of the spine to near the middle line of the body, it is manifest that the right iliac division has in a considerable degree the appearance and direction of the main trunk, whilst the left presents more the aspect of a branch. In a diagram from Quain's Anatomy,' the author shows that the angles which the right and left divisions of the aorta form with the abdominal aorta are respectively twenty-one and thirty-five degrees, showing that the right follows a course fourteen degrees nearer the direction of the aorta than the left does, and consequently, that it receives a more direct and stronger current of blood. The author refers to eleven preparations in the Anatomical Museums of Edinburgh which prove this point. Now, the cord being fixed at one end by its attachment to the placenta, cannot yield by twisting to the pulsating force conveyed through the hypogastric arteries; but the foetus floating freely in a fluid of its own specific gravity, readily gives way to the recoil acting on its pelvis; and from the position of the vessels at the umbilicus, the vein will represent the pivot on which it will move, whilst the right artery, having the greatest power of recoil, will determine the direction of the rotatory movement, that is, from right to left.

Mr. Simpson next applies his theory to the elucidation of the mode of production of convolution of the cord round the neck of the child. This is found almost always in one direction-namely, passing from the umbilicus over the right shoulder of the child, across the nape, then forward by the left side of the neck, and so on, according to the number of convolutions. This is also due to the unceasing pulsation of the foetal heart continuing the rotation of the foetus, so that its head passes into a loop of a long funis. If the funis be unusually long, the fœtus, at an early period of gestation, may pass completely through the loops, and thus form true knots upon the funis.

2. Professor Kussmaul describes a preparation of tubal gestation in the eighth or tenth week, in which the left Fallopian tube is developed into a fruit-sac at the point of its entry into the uterus, whilst the left ovary contains no corpus futeum, there being, however, two corpora lutea in the right ovary. The tubes are perfectly permeable down to the point where the fruit-sac is situated in the left tube, where a thick bunch of chorial villi stops the way. This being removed, the left tube is also free. Kussmaul concludes that the ovum developed in the left tube had passed down the right tube, and across the cavity of the uterus; and cites the following instances as similar to this one: 1. The cases of transmigration of the ova from the ovary of one side into the uterine horn of the opposite side in animals with uterus bicornis (Bischoff). 2. The case of transmigration of the human ovum from the ovary of one side into the rudimentarilydeveloped uterine horn of the opposite side (Scanzoni). 3. The case observed by Drejer and Eschricht at Copenhagen. 4. The observations of the development of the placenta on the one side of the uterus, whilst the corpora lutea were found on the opposite side. 5. The case of Oldham and Wharton Jones, in which the ovum apparently passed directly from the ovary into the tube of the other side, which had become adherent to it, developing itself in the uterine walls, and in which death followed the bursting of the sac.

The violent uterine colics and general spasmodic attacks which women in these cases suffer during menstruation, deserve attention. In the present case, according to Kussmaul's view, the transmigration of the ovum took place through the uterine cramp and antiperistaltic motion of the uterine end of the tube.

1. Contribution to the


Knowledge of Gestation outside the Uterus. By PROFESSOR HECKER. (Monatschr. f. Geburtsk., Feb. 1859.)

2. Case of Extra-uterine Pregnancy complicated with general Anasarca and Ossifi cation of the Uterus. By R. W. HARDEE, M.D. (North Amer. Med. Chir. Rev., May, 1859.)

3. Case of Tubal Pregnancy with Rupture and Death. (North Amer. Med. Chir. Rev., May, 1859.)


4. A Case of Placenta Prævia Succenturiala. By Dr. KUENEKE. (Monatsch. f. Geburtsk., May, 1859.)

5. Laceration of the Right Sacroiliac Synchondrosis during Labour. By SCANZONI. (Allgem. Wiener Med. Zeitz., No. 8, 1859; and Schmidt's Jahrb., No. 7, 1859.)

6. On Uterine Catheterisation, with Catgut for the Induction of Premature Labour. By C. BRAUN. (Monatsschr. f. Geburtsk., May, 1859.)

7. A Case of Spontaneous Rupture of the Uterus. By KAPLER. (Monatschr. f. Geburtsk., April, 1859.)

1. Professor Hecker makes a valuable contribution to the knowledge of extra-uterine gestation. He relates in the first place a case which he considers to have been one of ovarian gestation-a well-made woman, aged twenty-eight, who had borne a first child three years before. From that time she had menstruated regularly until recently, when conception was suspected. Now often on rising from bed she experienced a peculiar syncopal feeling which impelled her to lie down again. Then retention of urine appeared, and on vaginal examination, the os uteri was found pressed against the pubes, and the postuterine region was filled by a firm elastic swelling resembling in size the uterus in the third month of pregnancy. This was taken for the retroverted uterus. Great efforts were made to effect reposition; during these, collapse took place, and death in half-an-hour.

The autopsy revealed from four to five pounds of blood in the abdominal cavity; the uterus not gravid, much inclined forward, enlarged, its inner surface plainly lined with a decidua; behind it was a cyst, which without regard to its relations was cut out, leaving the uterus in situ. The cyst was of the size of the head of a child two years old; its walls were thin, and it bore a great resemblance to a dropsical ovarium. In one spot it was rent open; it contained a well-formed male foetus, whose development corresponded to a pregnancy of eighteen or twenty weeks. Nothing could be detected in the corresponding Fallopian tubes, but at the lower part of the cyst was a swelling that was clearly recognised as the ovary. The idea of an after-union of the cyst with the ovary by adhesions was excluded by the most searching examination; they were evidently continuous and one. (There can be little doubt that the preg nant ovarian cyst was ruptured by the force used in attempting to reduce the supposed retroverted uterus.)

Professor Hecker then prosecutes an elaborate statistical inquiry into the various points connected with extra-uterine pregnancy. His analysis shows that frequently either a long pause in fertility precedes tubal gestation, or there has been previous sterility. That this sterility and the tubal gestation are co-effects of the same cause, is proved by dissections.

The lapse of time from the first appearance of symptoms of illness to death was in two-thirds of the cases (48) within twenty-four hours, and in more than half of these in twelve hours.

Of sixty-four dissections, in 37 cases the gestation was found in the left tube, and in 27 in the right.

Of 31 cases, at the time of rupture of the tube, the fœtus was five weeks old in 1 case, six weeks in 5 cases, six to seven in 4 cases, six to eight weeks in

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