a periosteal and ligamentous sheath was left tolerably complete. The patient had a long and chequered convalescence, but at last recovered well with reproduction of bone within and from the periosteal sheath. The proof of this last statement, namely, that the regenerated bone was produced from the periosteum and not from the cut extremity of the old bone, lay chiefly in the fact that during convalescence there was for some time mobility of the upper and new piece of the humerus on the lower and old part, which could not have happened had the new bone been developed continuously with the old. The movements of the shoulder joint were fairly restored, and although no new head to the humerus could ever be felt, there was evidently the restoration of a scapulo-humeral joint of the same type as the original. For, adds M. Ollier, not only were the chief movements restored, but the humerus could be rotated on its own axis, and the deltoid separated the elbow from the trunk to a distance of six inches. To objectors to subperiosteal resections on the score of the difficulty of separating the periosteum from the bone the author points out that the membrane is thicker and less adherent in young subjects than old, and thicker and less adherent in inflamed than in healthy bone.

The next portion of M. Ollier's work is devoted to the consideration of the best method of performing the operation, and he lays especial stress on the advisability of cutting neither muscle nor tendon; and if the former be divided of necessity its nerve should be carefully avoided. By thus operating carefully, the tendons are left with their attachments to the periosteum, uninjured; and, in resections of joints, there remains an almost uninterrupted fibrous loge formed by periosteum, tendons, ligaments, and capsule, to which the muscles preserve their proper attachments. Other practical instructions are given by the author, and will well repay perusal. The following are his general rules for the operation as performed on the joints:

1. A single straight or sinuous incision through the skin in the direction of the long axis of the limb. If absolutely necessary, incisions perpendicular to the main one must be made.

2. A single straight incision of the capsule.

3. The ends of the bones should be dislocated before being sawn, in almost all cases but those of the wrist and ankle.

4. If the condition of the bones beyond the line of section require it, the gouge may be used; but évidement should not be practised before resec

tion.

5. The resected bones should be kept extended unless when a bony anchylosis is required. The degree of extension must be in proportion to the expectation of regeneration.

Special instructions are also given by the author for the resection of each joint.

M. Ollier's favourite instrument is one which he has named the "Sonderugine," and which is a long gouge, curved so as to allow of its being used as a protection to the periosteum after it has separated it from the bone. It is pierced at its extremity, so as to serve for carrying a chain-saw around the bone after the separation of the periosteum. For cutting the bone he prefers the bone-forceps when practicable and the chain-saw when a saw is absolutely necessary; the great object being to divide the bone with as little difficulty as possible, and to avoid all disturbance, especially of the periosteum, beyond the line at which the section is to be made.

With the operation of subperiosteal resection, the use of nitrate of silver or the actual cautery may be combined, when fungous granulations or fistulous tracks seem to render either of them necessary.

The degree of extension to be kept up after the operation depends on the chance of a good result. In a young subject, for instance, with a tolerably healthy state of the bone, much more regeneration may, of course, be expected than in the presence of the opposite conditions, and therefore more extension may be safely applied.

[M. SEDILLOT, of Strasburg, says:]

Subperiosteal resections should be rejected as illogical, inefficacious, and

dangerous::-"We maintain that the periosteum completely separated from the bone beneath, whether it be left in its place or taken to another part of the body, as a sheath or flap, will be of no service to surgery as the means and organ of regeneration of bones." And many other sentences of the same kind might be quoted. Referring to M. Ollier's experiments on the lower animals, he remarks that curious as they are physiologically, they are useless to surgery.

[M. Sedillot's favourite operation is that of évidement or gouging out the diseased portion of bone.]

Theoretically, M. Sedillot's position is a good one. "The first indication is to avoid the sacrifice of any healthy part of the skeleton, since this portion, clothed by its periosteum, is the most efficacious and certain means of reproducing the whole of the bone. Such is the foundation of our method of évidement, and our gravest objection to subperiosteal resection." Like his opponent, he refers to the benefit derivable from leaving unharmed the connections of the periosteum with the parts around. So far, of course, the author is justified in holding his own; but in the face of M. Ollier's cases, as well as those of others, the following sentence is rather inexplicable :-"What has happened to the partisans of subperiosteal resections? They have taken away the bone. The periosteum, unsupported, becomes shrunken, and is folded by the contraction of the muscles; it inflames and suppurates. In the majority of cases the limb is shortened and deformed with no production of new bone."

Some experiments on young dogs, to test the degree of repair possible after gouging out the interior of bones, and leaving only a thin layer in contact with the periosteum, were undertaken by M. Sedillot, and followed by good results:—“ Les évidements des diaphyses et des extrémités des os sans destruction des lames osseuses periphériques et par conséquent sans pénétration dans les jointures, ont toujours réussi."

The cases of disease in which évidement is useful and practicable, according to M. Sedillot, are chronic inflammations of bone, tubercular disease of the articular extremities, fibrous, vascular, encysted, and certain limited enchondromatous tumours. The operation, too, may be employed as an assistant to articular resections, and by its means much less bone is required to be removed. The operation itself, as we have said before, resembles very nearly that undertaken so frequently by almost all surgeons for the removal of carious bone, but involves more methodical dissection of the periosteum than is common in this country; and the gouge is especially employed so as to leave only a thin shell of bone immediately within and supporting the periosteum.

A large part of M. Sedillot's work is occupied by the relation of instances in which the foregoing operation has been employed by himself or others. The difference, however, between his method and that of other surgeons is not so great that we can afford space for quoting from his cases. It seems to us rather that these operations should be classed with the ordinary gouge operations, and the two compared with subperiosteal resections as performed by M. Ollier and others.

Dr. Stokes's paper on "Periosteal Preservation in Operative Surgery" is probably fresh in the memory of most of our readers. It is a very good and practical résumé of his own personal experience on the subject. He is an earnest supporter of Professor Syme and Langenbeck and M. Ollier; and, indeed, his attention was specially directed to this subject during attendance on the cliniques of the two last-named surgeons.

The two following cases may be quoted from Dr. Stokes's experience in this matter; and he relates several others.

"The first of these operations was performed on a girl aged 12, of delicate habit, who was under my care in the autumn of 1864, and who suffered from strumous disease in her left elbow-joint. The patient stated that, four months previous to her admission into hospital, she received a fall in which the elbow was struck against the ground with great violence. After falling, the patient suffered severe pain in the joint; it swelled greatly; and she found it im

possible to extend or 'stretch' it, to use the patient's own expression. The inability of extension of the arm remained a permanent condition. Three months after the accident, the patient was admitted into my wards in the hospital. I found the arm forcibly flexed; extension was impossible. The soft parts about the joint were swollen and puffy, so that it was quite impossible to determine whether the original injury was an epiphysary disjunction, which the age of the patient rendered probable, or a simple luxation. There were three or four sinuses, situated over and in the immediate vicinity of the internal condyle; and, on introducing a probe into any one of these, the existence of soft diseased bone could be readily determined. I accordingly performed the operation, adopting the long vertical incision, carrying it over the ulnar side of the olecranon, and, taking especial care not to divide the triceps tendon, proceeded to raise the periosteal envelope by means of the various formed raspatories devised for the purpose. The elevation of the periosteum was not attended with any great difficulty, and the remaining steps of the operation were then completed in the ordinary manner. limb was afterwards put up in a gypsum bandage, and kept in a continual bath for four weeks. After this, the wound being all but healed, gradual flexion and extension were commenced. Three months and a half after the operation, the power and flexion and extension of the joint was almost perfect; and now, at a period of little more than three years after the operation, during which period there has not been the slightest evidence of a reappearance of the disease, the patient enjoys every motion that the healthy joint possesses, perfect power of flexion, extension, pronation, and supination; and what bears more directly on the immediate subject of this communication, there is a most obvious osseous re-formation, not only of the condyles, but also of the olecranon. This re-formation of the olecranon has also been frequently observed by Langenbeck, and also by Huctor, one of his former assistants."

The

The other case which we shall quote from Dr. Stokes's paper also, as he remarks, affords a striking illustration of the osteogenetic properties of periosteum, and, consequently, of the great practical importance of preserving it in resections.

The patient, a young woman, about 19 years of age, suffered from suppurative osteitis of the right ulna, the result of a severe blow. A free incision was made down to the bones; and over this, which I found extensively diseased, the periosteum was much thickened. Having divided the membrane by one of Nélaton's so-called periosteal knives, I then detached it by means of raspatories from off each side of the bone. The diseased portion of bone, about two and a half inches in length, was then removed by small resection-saws. Three months after the operation, the wound was completely healed. New bone had formed throughout, and the patient was enabled to return to her employment, which was that of a house-servant."

Dr. Stokes has also practised with success M. Ollier's operation for the restoration of the bone by including in his flap periosteum from the frontal bone. The case was one of a young man whose nasal bones had been completely destroyed by lupus. About fifteen months after the operation, I inserted in two different situations in the nose the so-called entomologist" pins down to the newly-formed bone, and satisfied myself and others present, beyond all doubt, as to its existence."-British and Foreign Medico-Chirurgical Review, April, 1869, p. 334.

54. ON THE TREATMENT OF FRACTURES OF THE LEG.

By JAMES PAGET, Esq., F. R. S., Surgeon to St. Bartholomew s Hospital.

[All the cases of fracture referred to in the following clinical lecture were admitted into the hospital within a period of one week, in consequence of the occurrence of what is known as boxing night at the London theatres.]

That is

All these fractures that I have mentioned were put up at once. the custom which we adopt here. I think that, as you watch fractures, you will find that there are very few instances indeed in which you need depart from this rule-very few in which the damage done is such as to make it at all advisable to leave the fracture for a time, imperfectly at rest, on a pillow for any supposed righting of the fragments, diminution of swelling, or other supposed change for the better. I do not say that there are no such cases; each case is to be judged upon its own special grounds; but you may always begin the treatment of a fracture with a strong prejudice in favour of putting it up at once.

With regard to the manner of putting up a fracture, you will always have your choice of what is called the immovable apparatus, with gutta percha, and starched bandage, or gum and chalk, or what I more commonly use, plaster of Paris. There is no question of the considerable advantage of these in the commonest and simplest forms of fracture of the lower or upper extremity; yet I think that this apparatus should be used among outpatients only when you can be sure that the patient possesses sobriety and intelligence enough, and home comfort enough, to be able to manage his apparatus in some measure for himself. And the security of putting up fractures with splints and suspending them, as we do here, is so much greater, that if we have to admit the patients into the hospital, and to keep them here, we always adopt this plan first, except in the very simplest form of fracture of the leg. It is of this manner that I am now going to speak to you -the manner in which, in my wards, we put up fractures of the leg, whether of tibia and fibula, or of either bone alone.

Here is the apparatus, the principal thing about which I take to be this back splint. As you look at that and compare it with the back splints commonly made, you will see first that it is narrower than they are; so that for a man of full size the splint is not usually, at its widest, more than three and a half inches wide. It is narrowest about the ankle, where it is two and a half inches wide, and beyond which there is a large opening in it for the heel. Moreover you see the splint is nearly flat transversely; it is not hollowed out, as it is supposed it should be, to fit the back of the limb. Then it is very little curved; so little curved that you will say that it could not fit the leg of a very robust man. The calf, you would say, could never rest on that. But you must remember that you want a splint that is to fit the leg, not only at the time of admission, but also, and much more, the leg as it will be some ten days or a fortnight afterwards, when the leg has begun to waste, when the calf has fallen flat-gone to nothing. On a very curved splint, one that fitted the leg in the first instance, there will be no comfort after the lapse of a week, when the leg begins to waste. This splint is perfectly simple in its structure, a long and nearly flat piece of iron, bent at a right angle for the foot, and having two short transverse bars projected from its sides and looped to receive the slings. I would have you observe the direction of the footpiece, which is simply turned up from the back-piece of the splint, and turned to very nearly a right angle with the line of the back part, quite straight, narrow, and perfectly simple. On that arrangement of the foot-piece depends mainly the arrangement of the limb.

Besides this there are these two flat, wooden side-splints, duly padded like the back splint, and with care taken that they should be sufficiently long for the ends to project a little beyond the foot-piece of the back-splint, and to reach to some three or four inches above the patella. They should, moreover, always be broad enough to enable the straps that are put round them completely to encompass them without touching the leg. It is important for the comfort of the patient that no strap should come in contact with the front of his leg, and, after all, however one may regard anatomical considerations in putting up a fracture, the one most essential idea is that of comfort. If the patient is so disquieted by any of his apparatus that he cannot lie well or sleep well, the good progress of the fracture is a thing hardly possible; and great disquietude is produced by straps, bandages, or cutting edges of any kind which come in contact with any part of the skin.

The rest of the apparatus consists simply of pads stuffed with tow, one for each splint; and of the means, which I will presently speak of, for securing the foot to the foot-piece, and the knee to the back-splint; and then besides, the simple cradle that we have, with the double bar on the top for suspension by the loops of the transverse bars fixed to the back-splint. There is also a prolonged piece of iron from the distal end of the cradle to secure that the bed-clothes shall in no case touch the foot-piece or any part of the apparatus, or the patient's leg.

Then observe how the patient's leg is set upon this back-splint. I do not speak of the manner of reducing the fracture; that must depend on the considerations that I spoke of the other day. The limb having been put into a right position, it is simply laid on the back-splint, with no additional pad beyond that which is fastened to the splint itself, unless in some cases where there is a great hollow above the os calcis, and then it is very useful to have a pad under the tendo Achillis-an additional pad to that with which the splint itself is covered. But the chief thing is the fixing the foot to the footpiece.

You will observe, if you examine fractures of the leg that have united badly, that there is not one way, but several, in which the leg may be spoiled. First of all there is shortening. That comes, generally speaking, either from the fracture being so oblique that it is hardly possible to prevent one portion of the bone from sliding on the other, or from insufficient extension having been used at the time of setting. But there are other distortions which are really worse than shortening, for shortening can be corrected by adding something to the sole of the boot or shoe. A worse distortion than this is when the foot is rotated outwards, so that when the man gets up from what is supposed to be the cure of the fracture, he walks with the toe of the fractured limb not directed forwards like the other, but rotated outwards, a position in which firmness of support is hardly possible. And there is a worse thing than that. It is when the patient rises from the fracture with the sole of the foot either inverted or everted, so that from that time he has to walk, not fairly on the flat of his foot, but on the outer or inner margin of it. It is from want of care in reference to that distortion that fractures of the fibula are sometimes followed by one of the greatest miseries that can result from fracture of the lower extremity; for when a patient is consigned for life to walk on the inner or outer margin of his foot, he loses I know not how large a proportion of the proper strength of his limb, and nearly all the comfort of his walking. He is in the position of a person who has been congenitally deformed, so as to walk on an inverted or everted foot. He is as ill off as those with varus or valgus; nay, he is in a worse condition than they are, because his case, depending as it does upon distortion of the bones, and not of the joints, scarcely admits of repair. No apparatus can put a patient into comfort who rises from fractured fibula or fractured tibia and fibula with this defect.

Take, therefore, the foot-piece of the splint as the guide for the position. of the foot; and if you do but see, in the management of fractures of the leg, that the foot of the patient and the foot-piece of the back-splint fairly correspond, it is hardly possible for the limb to fall into any of these defective methods of repair. That correspondence between the axis of the foot and of the foot-piece ensures that there shall be no rotation or version either outwards or inwards. Then, again, you should be careful that the foot touches the foot-piece by the three balls of the sole-the ball of the heel, the ball of the great toe, and the ball of the little toe. If the foot be set against the foot-piece so that these three chief points, upon which in standing or walking it rests, are in exact contact with the foot-piece, or nearly and evenly approximated to it, when the patient rises with the fracture healed they must hold the same position, and he be ready at once to bear his weight upon these three points, For the rest, this upper curved part of the splint must come in contact with the popliteal space, and you will observe that this upper part is very little curved, so that the limb is very little bent at the knee-joint. That is a most important thing to attend to, for if there be too