hospital. I will especially refer, however, to one of the latest cases which has come under treatment in the hospital-namely, that of Mary C., in Princess's ward. This patient had suffered from rheumatic inflammation, and was admitted into the hospital with partial anchylosis of the knee and of the ankle. The tendo Achillis was divided, and, when the puncture had healed, the adhesions were ruptured by flexing the foot upon the leg. On a subsequent occasion the hamstrings were divided subcutaneously, and, the punctures having healed, the adhesions at the knee-joint were ruptured by flexing the leg upon the thigh. This patient walked well when she left the hospital, and without the least lameness; and the knee and ankle of the affected side were as free as those which had not required operation.

It is a point to remember, that after dividing the tendons, and before the punctures have healed, the adhesions should not be ruptured; or they should be ruptured only with great care, lest the puncture should be extended into a rent. This extension of the puncture is much easier to effect than might be supposed, and it is therefore safer to allow the punctures to close before any force is employed.-Lancet, Feb. 6, 1869, p. 181.

51.-ON A CASE OF SUBPERIOSTEAL EXCISION OF THE ELBOW.

By T. HOLMES, Esq., Surgeon to St. George's Hospital. [The fact of the reproduction of considerable portions of bone, when the periosteum which covered the original bone has been left entire, is established by cases published by Langenbeck and Mr. Joseph Bell. In the great work of M. Ollier an account is given of all (except the most recent) cases in which such reproduction has been ascertained.]

Upon the strength of these authorities, let us assume, then, that if the whole thickness of a bone be dissected out of its periosteal sheath, there is, under favourable circumstances, a probability of its reproduction-between limits which our present experience is as yet insufficient to point out :-can this fact be used in any way to improve the results of excision of the joints? I will only speak of the superiosteal excision of the elbow-joint, because this is the only operation of the kind of which I have had personal experience; and also because there are far larger and more trustworthy data in surgical literature for forming an opinion as to the value of this, than of any of the other subperiosteal excisions.

I will, in the first place, present to you my patient, and read extracts from the notes of the case:

The patient, a boy aged 12, was admitted October 14, three weeks after an accident, in which the joint had been laid open by the point of a pair of scissors, which ran in between the external condyle and the head of the radius. Soon after his admission, the head of the radius separated from its shaft and came away; and as a considerable portion of the humerus was still bare, and there was great pain, suppuration, and loss of motion, the joint was excised subperiosteally on November 19, the humerus being removed above the condyles and the ulna, just through the coronoid process. The radius was not interfered with. The periosteum separated easily from the bones. A slight accident occurred in passing the chain-saw round the humerus, but its section was easily accomplished with an ordinary keyhole-saw. Its structure was much condensed by inflammation.

All went on well after the operation. At the date of this lecture, January 13, 1869, eight weeks after the operation, the wounds were entirely healed; passive motion could be accomplished through about 30°; the child could carry the hand to the mouth and head, but had gained little voluntary power, though this was then daily improving. There was a great deal of thickening around the end of the humerus.

The operation is simple enough. The incision which most surgeons now generally use will serve, viz., a single longitudinal cut running between the olecranon and outer condyle. The surgeon has at hand a number of "raspatories" or chisels of various shapes-som some with blunt, others with sharp edges; and it is well, in order to avoid loss of time in an operation, to have the handles of the sharp and blunt raspatories made differently. Having cut down quite freely on to the olecranon, and divided the periosteum covering it, the operator proceeds to detach the membrane carefully from the bone, taking care to proceed slowly, and not to use such violence as may lacerate the periosteum. The triceps tendon is also separated by keeping the edge of the sharp raspatory (or "detache-tendon," as Ollier calls it) carefully applied to the point of the process, while directing the instrument at right angles with it. Having thus cleaned the olecranan, the surgeon proceeds to deal in the same way with the back of the humerus, and the common tendons springing from its condyles. The ulnar nerve is, of course, raised up with the other soft parts covering the inner condyle, and will not usually be seen. When the back of the humerus has been satisfactorily cleaned, the chain-saw is to be carried between its front surface and the periosteum. This is accomplished by pushing the curved raspatory, which I show you here, between the periosteum and the bone. You will see that this raspatory

is deeply grooved, and that it has a sort of eye near its end. In this eye is threaded a ligature attached to the chainsaw, and thus the chain-saw is drawn up the groove of the raspatory, and lodged between the periosteum and bone. After the humerus has been divided it is to be seized with the lionforceps, tilted backwards, and cleaned from the periosteum which coats its anterior face. The coronoid process will then be fully exposed, and should be carefully cleaned from the periosteum and tendon.

I have practised this operation on the dead subject often enough to have assured myself that in ordinary circumstances it is quite feasible. Huëter says, however, that in Langenbeck's experience several cases have been met with where the periosteum was not separable from the bone. In such cases, no harm has been done beyond the loss of a minute or two, and the operation can be finished in the common way.

The main advantage claimed for the subperiosteal operation is that the joint may be regenerated, and thus a more useful and more powerful arm be obtained. The reality of such reproduction is attested by the assertions of numerous operators, that after excision has been practised in this method they have distinctly felt the olecranon and condyles of the humerus reproduced. This is a matter on which a surgeon of experience can hardly be deceived; but it is of course more satisfactory to have the dissection of the parts; and this conclusive proof has now been furnished by a case published by Dr. Doutrelepont in the last number of Langenbeck's "Archiv." Bd. ix. p. 911. In this case subperiosteal excision of the elbow was performed at the age of 18, about four years before death. Two-thirds of an inch of the humerus was removed, the section running through the condyles; the olecranon and coronoid process of the ulna (1 inches) and the head of the radius were also removed. The drawings attached to Dr. Doutrelepont's paper show that the condyles of the humerus had been entirely reproduced, the internal condyle rather exuberantly, so as to form a deep groove for the ulnar nerve. The olecranon was also reproduced, and was both longer and more curved than in the natural state -a circumstance to which I must recur hereafter. The head of the radius was also reproduced, and was united to the ulna by an orbicular ligament as in the natural joint. There was a regular joint between the ulna and humerus (an articular surface, surrounded by a capsule, being formed on the summit o the reproduced sigmoid notch), and true hyaline cartilage had also been reproduced. There was no appreciable shortening o the arm, and the muscles were as well developed on that side as on the other. Pronation and supination were almost natural ;

and flexion and extension were perfectly good, but within the limits of 75° to 120° only.

This case is a perfectly conclusive proof of the reality of reproduction of the bones, and of the formation of a true articulation (with cartilage and capsule complete) after the operation in question.-Practitioner, Feb. 1869, p. 65.

52. ON THE REDUCTION OF OLD DISLOCATIONS. By BERNARD E. BRODHURST, Esq., Assistant Surgeon to St. George's Hospital.

[It was laid down as a rule by Sir Astley Cooper, that in dislocations of the hip, attempts at reduction should not be made after eight weeks of displacement, and in those of the shoulder after three months. The use of chloroform, however, compels us to re-consider and modify our opinions on such questions as these.]

The mode in which reduction of an old dislocation should be proceeded with, that the operation may have a successful issue, is of great importance. I will relate two cases as examples of successful reductions of long-standing dislocations, which will together illustrate perhaps every point that it is necessary to consider.

It is doubtful if the capsule is ever an obstacle to the return of the dislocated bone. Certainly the altered shape of the head of the bone never can prevent the return of the head to its articular cavity. And it is probable that where the articular cavity is partially obliterated, it is the result of extraordinary violence and consequent inflammation. I have found the cotyloid cavity retaining its depth and covered with cartilage after the head of the femur had been dislocated for three years. And Fournier has placed a dissection on record where the head of the femur had been dislocated during thirteen years, and in which the acetabulum retained its form and depth and cartilage.

Chloroform having been fully administered, the adhesions around the extremity of the bone are to be ruptured by free movements of the limb, and these having been separated, the dislocated bone will be replaced by traction and manipulation, and without extension and the use of the' pulleys. In some cases it is necessary to have recourse to the subcutaneous section of tendons before proceeding to reduce the dislocation; and when this is done, the punctures should be allowed to heal before attempts at reduction are made.

Some time ago, I saw, with Mr. Chalk, a patient, fifty-three years of age, who had fallen from a height of twenty feet and dislocated the humerus beneath the pectoral muscle. The swell

ing was considerable at the time, so that the dislocation was not discovered by the surgeon who first saw this patient; but afterwards, an attempt at reduction was made, which, however, was not successful. Four months later, he presented himself at a large metropolitan hospital, that an attempt at reduction might be made. He was persuaded, however, not to submit to any attempt to replace the head of the bone. Two months after this, I saw him. He was suffering acutely, and was unable to move the limb, or to carry it without support. Any attempt at motion caused excessive pain, especially about the neck of the humerus and in the region of the elbow.

The head of the humerus could be distinctly felt lying beneath the pectoral muscle, where it appeared to be firmly fixed. The deltoid, biceps, and pectoral muscles especially were atrophied; but also the whole limb was wasted. The fingers were numb. The elbow was somewhat removed from the side, and was inclined backwards, where it was fixed and immovable; the forearm was flexed, and the hand was carried forwards.

Under these circumstances, we determined to endeavour to replace the head of the bone; and although the humerus had been dislocated now for 175 days, we considered ourselves justified in making the attempt at reduction. The patient was therefore placed completely under the influence of chloroform, and the scapula was firmly fixed both laterally and from above. The adhesions about the head of the humerus were then broken up by to and fro motions of the humerus and by freely rotating the head of the bone. Then seizing the wrist, I drew the arm directly upwards, when the head of the humerus immediately slipped into the glenoid cavity with a slight click. A pad was placed in the axilla, and the arm was bandaged to the side. The patient remained in bed for three days, and on the sixth day the bandages were discontinued, and gentle motion was commenced. There was no disposition at any time for the bone again to become displaced.

After some considerable time, the power of motion was in great measure, if not entirely, restored; pain and numbness ceased, and there was no difference in the fulness of the two shoulders; so that when I last saw him, this arm was almost as useful as the other.

On the 8th of July, 1868, Elizabeth Costin, nineteen years of age, was admitted into the hospital with an old dislocation of the wrist forwards. This dislocation resulted from a fall on to the palmar surface of the extended fingers, and it occurred six years before her admission into the hospital. The wrist and fingers had entirely lost all power of motion. On the day after ber admission into the hospital, the flexor tendons, namely those of flexor carpi radialis, palmaris longus, flexor sublimis,