CRITICAL ANALYSIS

OF

ENGLISH AND FOREIGN LITERATURE

RELATIVE TO THE VARIOUS BRANCHES OF

Medical Science.

Quæ laudanda forent, et quæ culpanda, vicissim

Illa, prius, éretâ; mox hæc, carbone, notamus,-PERSIUS.

DIVISION I.

ENGLISH.

ART. IA Treatise on Dislocations, and on Fractures of the Joints. By Sir ASTLEY COOPER, Bart.. F.R.S. Surgeon to the King, &c. &c. &c.-1 vol. 4to. 30 plates, pp. 562. Longman and Co. London. ON resuming our critical labours at the commencement of a new year, we may, perhaps, be permitted to say a few words rela tive to an occupation so useful, and yet so invidious, so necessary to be done, and yet so difficult to do with satisfaction to the sensitive feelings of an author, or the rigid scrutiny of the indifferent or sceptical. That we have hit this nice point, we do not even dream of asserting; but we have assuredly endeavoured to do so: we have uniformly taken up the book to be reviewed, with a determination to forget, as far as possible, the author; to extract whatever we found to be useful, or new in theory or practice; to reprehend what we conceived to be erro❤ neous in either, so that the profession at large, and the junior part of it in particular, should not be misled by false doctrines sanctioned by high authority: nor should the good be passed by, because it presented itself to us in an unassuming, or perhaps, even in an homely, garb. Upon all occasions we have endeavoured to separate the author from his work: the latter is public property, the former is sacred: the work may, if faulty, be productive of incalculable mischief, and must be exposed; our duty to our readers demands it, and, as far as our judgment and abilities permit, this object it shall always be our aim to accomplish. This intellectual dissection we will endeavour to perform in as cleanly and decent a manner as we can; for, in this, as in other dissections, the design is not to expose the subject, but to instruct the lookers on..

From this short digression we turn to the splendid work before us; in bulk, in beauty of paper and type, in the number of plates, and in the excellence of their execution, surpassing any modern publication on a professional subject with which we

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are acquainted, at least in this country. On turning over the pages of this book, we were at first tempted to exclaim against the numerous errata of the press which we encountered on every side; but, when we began the perusal seriatim, we were so struck with the author's candid avowal of this error, that we were induced to strike out the reprehension which this unlucky discovery had elicited. However, we must notice particularly one of these errata in this place, because it is not corrected, and it directly affects the sense of the passage: it occurs in page 338, and will be more particularly pointed out in its place. Our experienced author also endeavours to obviate any objection that may be raised against the familiar and occasionally colloquial style of the work; declaring "that he had rather be seen in a good plain suit, than in the finest embroidered dress." (Preface, p. vii.) It is, however, to be recollected that a certain attention to dress is necessary to obtain admission into the best society; and (dropping the metaphor) that, as this volume is intended to go down to posterity, and will most assuredly do so, the style is a matter of more importance than in those ephemeral publications which are born only to die.

Many may consider these preliminary remarks, perhaps, as rather fastidious; but let them recollect that Sir ASTLEY COOPER is likely to be quoted as an authority, and followed as an example; and, therefore, it behoves us more especially to notice those points in which he has failed, lest they should be adopted by others who do not possess his eminent and redeeming merits.

We have but one more remark to make before we enter upon the analysis of the work, and that remark relates to the price at which this book has been published: certainly a very noble instance of liberality on the part of the author, but which must not lead us to form unfair conclusions with respect to other authors less fortunately circumstanced, and who have it not in their power, whatever their wishes might suggest, to follow this splendid example.

Sir

The bulk of this volume consists of a reprint of the Essays on Dislocation, published in the octavo edition, with some additional matter: the plates, however, are new, and increased both in number and size, as well as in beauty of execution. Astley Cooper informs those who are in possession of the former edition, that, for their convenience, he will print the additional matter in the octavo form, provided they express their wishes and send their names and address to him, within three months after this publication.

Sir A. Cooper commences his work with remarks on dislocations in general, and almost immediately details an interview which a patient, whose shoulder had been dislocated "many

weeks," had with him. It appears that the surgeon in the country had mistaken the nature of the accident; and our author's advice to the patient was, not to suffer any attempt at reduction. We do not in the least doubt that Sir A. Cooper's advice was highly judicious; but he seems to anticipate, in his preface, that his professional brethren may imagine that he has limited the period at which reduction may be attempted too strictly and, with respect to dislocations of the shoulder, there is some reason to think that he has. "A considerable share of anatomical knowledge" (we quote Sir Astley's words,)“ is required to detect the nature of these accidents, as well as to suggest the best means of reduction; and it is much to be lamented that students neglect to inform themselves sufficiently of the structure of the joints. They often dissect the muscles of a limb with great neatness and minuteness, and then throw it away without any examination of the ligaments; a knowledge of which, in a surgical point of view, is of infinitely greater importance. We have printed this very important remark in italics, in order to call the particular attention of our younger readers to it, fully agreeing with our author, both in the truth of his remark, and great importance of impressing it strongly on the minds of all classes of students in our profession.

Yet, with the most accurate knowledge of the structure of the joints, the tumefaction and tension arising from the injury occasionally so obscure the nature of the accident as to render it extremely difficult to be detected; therefore, conclusions drawn when the swelling has subsided, the muscles are wasted, and the head of the bone can be distinctly felt, would be both "illiberal and unjust.”

The immediate effect of a dislocation is to alter the form of the joint; often to produce a change in the length of the limb, to occasion the almost entire loss of motion, and to alter the axis of the limb. In the first moments of the dislocation, it is to be remembered that considerable motion remains. In a case at Guy's Hospital, where the thigh was dislocated into the foramen ovale, a great degree of mobility of the bone existed at the dislocated part, but in less than three hours it became firmly fixed in its new situation by the permanent contraction of the muscles. This is very important to remember, because mobility of the bone is one of the most marked symptoms of a fracture of its neck, though in this case the knee is turned outwards. After describing the usual criteria by which dislocations are known, Sir Astley observes that, among the more remote effects of these accidents, the crepitas produced by the effusion of adhesive matter into the joint and bursæ, may induce the practitioner, if he be not aware of it, to suspect a fracture where none has occurred. Inflammation of the joint occasionally is

also so severe as to produce suppuration, and to destroy the patient, even after the reduction of the dislocation; and two cases of fatal result are mentioned. (p. 7.) We believe this seldom occurs, except in dislocations of the thigh.

Sir Astley's description of the dissection of dislocated joints is, of course, accurate; but, as it presents no novelty, we pass on to observe, that dislocation sometimes arises merely from a relaxation of the ligaments of the joints, of which three instances are inserted, where the patella was dislocated in that manner. Relaxation or paralysis of the muscles will also sometimes produce the same effect; but these accidents may be considered as comparatively rare.

It is well known that the hip-joint frequently becomes dislocated in consequence of ulceration. Sir Astley Cooper mentions a preparation, now at St. Thomas's Hospital, where the knee was dislocated by ulceration; and a case of the same kind occurred in a boy, a patient at Guy's Hospital.

Dislocation accompanied with fracture is a common occurrence at the ankle-joint. At the hip joint, the acetabulum is occasionally broken off. The head of the humerus, and the coronoid process of the ulna, also may experience the same fate.

In the event of a fracture and dislocation occurring at the same time, our author advises the dislocation to be reduced before the fracture be adjusted, and confirms his opinion by the case of a gentleman who had his leg broken and his shoulder dislocated: the latter was not attempted to be reduced until a fortnight after the accident, and then the attempt failed, the fractured leg prohibiting the employment of the necessary degree of force.

A compound dislocation is next defined, its essence consisting in the exposure of the cavity of the joint, in addition to the displacement of the articulatory surfaces: of course, the effect is an extravasation of blood into the joint, and the escape of the synovia. (p. 18.) We need hardly add, that these accidents are declared by our author to be attended with great danger. In explaining the causes of this danger, Sir Astley says, "When a joint is opened, inflammation of the lacerated ligaments and synovial membrane speedily succeeds; in a few hours suppuration begins, and granulations arise from the synovial membrane, which, being a mucous membrane, is more disposed to the suppurative than to the adhesive inflammation." Here we humbly conceive there is a slight pathological error; we always regarded the essential characteristic of a mucous membrane to be, one which communicated with some external opening of the body; and we have been taught to consider the synovial membranes as a class by themselves. The leading circumstances that render this species of dislocation so serious are

then described; but the mode of treatment is deferred until the compound dislocations of the ankle are described, "where they will be better understood; and thus a repetition, which would be both irksome and useless to the reader, will be avoided." (p. 19.)

On the causes of dislocation, our author observes, that, when the muscles are unprepared for resistances, very slight accidents will often bring about the effect. A fall in walking will sometimes dislocate the hip-joint, when the muscles have been prepared for a different exertion.

Dislocations of the elbow-joint in children, Sir Astley thinks to be rare; such cases usually being, in reality, fractures of the condyles of the os humeri, which assume the appearance of dislocation in consequence of the radius and ulna being drawn back with the fractured condyle.

In enumerating the circumstances that impede reduction, our learned author mentions the form of particular bones, or the cavity that receives them, may in part occasion the difficulty. He very judiciously combats the supposition that the capsular ligaments resist reduction; neither do they appear to have any power in preventing the occurrence of the dislocation: it is the ligaments peculiar to the joints, and the tendons spread over them, that form the principal obstacles to the displacement of bones, and the resistance of the muscles which is the most for midable obstacle to their re-adjustment. When a bone has been long time displaced, the extremity also contracts adhesions to the surrounding parts. Sometimes also the socket of the bone becomes filled with adhesive matter; and, "lastly, a new bony socket is sometimes formed, in which the head of the bone is so completely confined that nothing but its fracture could allow it to escape from its new situation." (p. 29.)

...The means of reduction are divided by our author into constitutional and mechanical: the former are principally three,→→ bleeding, warm-bath, and nausea. Of these, Sir Astley consi ders bleeding the most powerful; and the operation should be performed in the erect position, in order that syncope may the more speedily be induced: an opinion in which we entirely concur, and which we are surprised to find so often mentioned by different professional men, and yet so seldom practised. The warm-bath is next recommended, the method of using which is sufficiently known; and the third plan is that of excit ing nausea, by means of tartarized antimony in small doses, which however will seldom succeed alone, as the operation of that medicine is so very uncertain and dissimilar in different individuals; and it becomes a matter of great difficulty to obtain the exact effect that we wish to produce. Our author, there

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