we shall conduce to the ultimate and not long-delayed relief of the parts involved, and therefore to the general comfort of the patient.

Whatever may be the worth of my explanation of the modus operandi of compression, as I have recommended it, in sprains and contusions and all analogous cases, I can unhesitatingly vouch for the superior efficacy of this plan of treatment. And if I succeed in merely drawing attention to my suggestion, I shall be satisfied, and shall feel at least non ego frustra.— Liverpool Medical and Surgical Reports, Oct. 18, 1868, p. 97.

48.-AN ARTERY COMPRESSOR SUGGESTED FOR THE TREATMENT OF SOME SURGICAL ANEURISMS.

By GEORGE H. PORTER, Esq., President of the Royal College of Surgeons in Ireland. Independent of the ligature, various attempts have been made to arrest the current of blood through exposed arteries, and to occlude them rapidly, or by degrees. Most ingenious appliances have been devised for the purpose, but they have never met with much favour at the hands of practical surgeons. Yet how painful it is to meet with cases of aneurism in situations where the experience of bold and able men tells that little can be done to save life. Among those who have endeavoured to close arteries without cutting through their coats may be mentioned Crampton, Percy, Deschamps, L'Estrange, Assalini, Dubois. If, however,

their instruments be scrutinized, I think it will be found that the disturbance to the vessel both in applying and removing them was too great, and the amount of pressure far beyond that required. In some situations the ligature has invariably failed, secondary hemorrhage following its separation. To meet such difficulties is my object. That the axillary artery could be compressed between a silver probe and loop of wire for fifty-two hours without damaging the vessel, I perfectly satisfied myself. I reported the case in the number of this Journal for November, 1867. In the instance I refer to the artery was not occluded, but considerably narrowed at the point of acupressure. No laceration of either the internal or middle coat took place, nor do I believe such a condition requisite to close a vessel.

Strongly impressed with such an idea, I consider a modification of acupressure may yet be brought to aid the practical surgeon in the cure of aneurisms hitherto unmanageable. The little instrument I venture to suggest to the profession is in reality a form of acupressure, simple in construction, easy of application, and yet powerful in restraining the current of blood, without rudely inflicting injury on the arterial coats. It consists of a piece of silver wire about the strength of an ordinary probe; this is bent into a triangular shape about four inches in length, and the apex surmounted by a small ring; the base is perforated by two little apertures just large enough to permit a fine wire to pass easily through. The wire is first carried round the deuuded artery in an aneurism needle with greater facility than a thick ligature, and each extremity of it passed through the holes

in the compressor; one end should be fastened by twisting it through the little ring at the top, and the compressor may then be gently pushed down on the vessel, when, by pulling the free end of the wire, the requisite pressure may be made to arrest the flow of blood through the artery. The wood

cut gives an accurate representation of the compressor, and the manner in which the wire is passed through, forming the loop which, with the instru ment, incloses the vessel in such a manner that slipping is impossible. When the artery is sufficiently occluded to stop the current, the free wire may be fastened also to the ring. The instrument can be removed with the greatest facility when pressure is no longer required, by cutting the wire at each side, lifting up the compressor, and then gently pulling the wire away from beneath the artery. I have placed this instrument on the femoral artery in the dead subject, and it closed the vessel so tightly that it prevented the injection of water through the artery, and the internal coat was not in the slightest degree injured. I have not had an opportunity of testing it in the living, but I suggest it to the notice of my professional brethren, hoping that they may be induced to give it a trial. We know that aneurisms have become consolidated, and cured in a few hours after shutting off the supply of blood to the sac, and should such a happy result follow the use of this instrument, it might at once be removed without having done any injury to the vessel; or if, on the other hand, it had been permitted to remain for fifty or sixty hours without curing the aneurism, it might be taken away, no harm having been done by its presence. It is so light in construction that no inconvenience is likely to be produced whilst in the wound leading to the denuded artery. Its action imitates, as nearly as possible, acupressure, which we know efficiently closes the cut extremities of large arteries.-Dublin Quarterly Journal, Feb. 1869, p. 8.

49.-TEALE'S MODE OF AMPUTATION.

[Mr. WHARTON, of Dublin, in a short article published in the British Medical Journal, of October 31, 1868, proposes to modify Teale's amputation, by dispensing with the short posterior flap. In answer to this Mr. Pridgin Teale writes:]

The reason why my father considered the short posterior flap to be necessary was this; that the posterior flap, being made as a rule of the powerful flexor muscles, retracts immediately almost to the point at which the bone is to be sawn through. If, however, the posterior tissues be divided opposite the point selected for sawing through the bone, they immediately retract to a point higher up, and thus leave the posterior surface of the bone projecting and denuded of soft tissues.

This fact would not be evident in practising the operation on the dead subject, in which the flaps, from non-retractility, appear superabundant.— British Med. Journal, Nov. 7, 1868, p. 509.

50.-ON AMPUTATION OF THE JOINTS.

By BERNARD E. BRODHURST, ESQ., Lecturer on Orthopaedic Surgery at St. George's Hospital. Anchylosis is either true or false. True anchylosis, or synostosis, implies that the soft structures of the joint have been destroyed, and that bony union has taken place between the adjacent bony surfaces; and by false anchylosis is understood the formation of membranous or fibrous adhesions within or external to a joint, and which interfere with motion.

False, partial, or fibrous anchylosis is induced, then, by the deposition of lymph within or around a joint, through which adhesions are formed which interfere with motion. Motion may be only slightly impeded, or it may be, in fact, lost. If the muscles about a joint, or the tendons which pass over the joint can be rendered prominent or tense, anchylosis is not complete; neither is it complete, or bony, should the slightest motion remain. ́ And even though motion be lost, the same sensation of solidity is not imparted to the hand on grasping the limb firmly above and below the articulation, as when bony anchylosis has taken place.

Fibrous or false anchylosis may be divided into two classes, which may be severally designated extra-capsular and intra capsular.

Extra-capsular anchy losis depends on inflan matory action, such as is induced by burns, phlegmonous erysipelas. mechanical injuries, and indeed every form of inflammation through which lymph is deposited around a joint; while intra-capsular anchy losis is occasioned by various forms of inflammation which have affected the structures within the joint, and through which adhesions have been formed.

Thus, the fibrinous deposit, whether within the joint or external to the capsule, becoming organised, occasions false anchylosis.

Lymph is poured out into the cellular tissue around a joint, and about the sheaths of the tendons and muscles in the immediate vicinity; it becomes organised, and the parts are more or less matted together and fixed, whether in an extended or a flexed position, and their functions are impaired. And when the interior of the joint is affected, instead of that portion of the limb external to the capsule, then, in a somewhat similar manner, adhesions are formed between opposed surfaces, the inflammatory product becomes organised, and motion is hindered. Both in intra- and in extra-capsular inflammation the amount of injury to the limb will depend in some measure on the character of the inflammation. It will depend much more, however, on the mode in which that inflammation has been treated; whether attentively from the commencement, with absolute rest, or negligently-allowing the use of the joint. And in proportion as the inflammation is of long duration, so in all probability will the adhesions which form be dense and extensive. When, however, disease is arrested, and the interior of the joint is restored to a healthy condition, the adhesions which have formed may be so dealt with that motion may be restored. In many cases the adhesions are slender, and although slender they may entirely prevent useful motion; or, again, they may be more extensive, and yet yield and allow of increased motion. When the articular surfaces occupy their normal positions, and the interior of the joint is restored to its integrity, motion may be restored. It is a notion now for ever banished, that partial anchylosis has yet to be endured, and that surgical art can offer no remedy.

In many cases of partial anchylosis there is, also, partial displacement of the articular surfaces. Some of these admit of rectification of the position of the limb; in the majority of instances, however, this amelioration can only be partially accomplished, and it cannot always be maintained even after tenotomy. It need not be said that there is no hope of restoring motion, in a permanent manner, unless the position of the limb as regards the articular surfaces is first restored.

The treatment of partial anchylosis may be divided into-1st, gradual extension with or without tenotomy; and 2nd, forcible flexion of the limb, with or without tenotomy, and subsequent gradual extension.

In all cases of partial anchylosis there exists some muscular rigidity; in some also, cicatrices are found, resulting from loss of substance. In cases where the adhesions are recent, contraction of a limb will probably yield to continued extension-such extension, namely, as is made by means of a welladjusted instrument for the purpose; but, except in cases of recent adhesions, it is generally necessary to commence the treatment by dividing the tendons of rigid muscles, and by dividing, subcutaneously, cicatrices. It is better to proceed at once to these subcutaneous sections rather than to prolong the treatment by extension unnecessarily; for, except when the adhesions are recent, simple extension is seldom so efficacious as when it is combined with subcutaneous sections. Even partial displacement of the articular surfaces is easily produced by continued extension without tenotomy. Indeed, this is not unfrequently seen to result at the knee when extension is long continued with rigid muscles. And, therefore, whenever it is desired to remove the contraction of a limb by extension, it is the rule first to divide the tendons of rigid muscles, and to divide cicatrices subcutaneously, and subsequently to proceed gradually to extend the limb.

But if such be the law of treatment where the articular surfaces occupy

their normal positions, it is even more to be insisted on when any displacement has taken place. Extension should then without fail be preceded by the subcutaneous section of such tendons, fasciæ, and cicatrices as might interfere with the readjustment of the articular surfaces.

These obstacles to extension then having been removed, a well-adapted instrument is to be applied to the limb, and extension is to be made slowly. The instrument should support the limb efficiently; and it should always, in the first instance, be applied to the limb at the same angle at which the limb was held before the subcutaneous sections were made. So soon then as the punctures have healed, extension may commence, and be continued without pain, and without producing displacement.

Numberless cases, however, exist in which the means above-mentioned are useless to restore to the limb either the normal position of its parts or to restore motion; cases, for instance, in which the adhesions are so firm that they do not yield to gradual extension; sloughs may be caused, and dislocations, partial or complete, may be produced; but the adhesions, whether intra- or extra-capsular, remain firm and unyielding. Injury alone, but no useful result, can accrue from gradual extension in these cases. Before chloroform was introduced, these were among the opprobria of surgery. Then, and indeed later, gradual extension of such limbs was continued for months without any advantage being derived; and the same system has been applied even where bony union rendered any benefit impossible.

Thus it is necessary, before proceeding to the treatment of a case of this kind, to form a correct diagnosis-to determine whether complete anchylosis has taken place, or whether the adhesions are fibrous; and if fibrous, whether they will yield to gradual extension or not. If these several points cannot be otherwise determined, chloroform should be fully administered, so that when muscular relaxation has been obtained, both the character of the adhesions and the amount of motion may be ascertained. When bony union has taken place, a sense of solidity and continuity of structure is communicated to the hands on grasping the limb above and below the articulation; but when fibrous union has formed, there is always more or less motion to be obtained. And if the adhesions are of such a character-so firm and unyielding, allowing of only slight motion, and with inconsiderable muscular retraction-that the normal position of the limb can only be gained by the forcible rupture of the adhesions, the force should be so applied that it is used mainly, if not entirely, in flexion of the limb.

Any tendons which are rigid should be first divided, and the punctures having healed, and chloroform having been fully administered, the limb to be operated on should be so firmly fixed that all motion is prevented, except that which the operator is about to impart to the limb. Thus, for instance, if the hip joint is to be operated on, the pelvis must be fixed; if the knee, the thigh must be securely held; and so on. When the limbs are thus firmly secured, the adhesions are to be instantaneously ruptured, by force applied in the direction of flexion. I say that the adhesions are instantaneously ruptured, when the patient is properly prepared, and the force is rightly adjusted. The limb is then to be bandaged, and the joint i sto be confined either in a guttapercha splint or in a flexible splint.

I know of no danger whatever from the use of force so applied. Indeed, when the influence of the muscles is perfectly removed, the adhesions themselves usually offer very little resistance; and if the power to be applied is sufficient for the purpose, the result is instantaneous. In a small number of instances, the hand alone is insufficient to rupture the adhesions readily; in these I make use of an instrument of great power to flex the limb. Not only is there no danger connected with this operation, but with moderate care it would seem to be impossible to set up unhealthy action. There are timid people who would persuade you that in these operations fracture is not uncommon; that inflammation is frequently excited; and they will proceed to detail a list of ills, with which I will not trouble you. Let it be sufficient for me to say that I have never seen a fracture produced, nor have I known inflammation to occur, nor any other ill whatever to follow an operation of

this nature; and that when disaster ensues it is from abus of the operation. I cannot tell what might be the result of adopting such instructions as the following, which I copy from one of the latest works on the subject. After describing the preliminaries of the operation, the author proceeds thus: "A cracking noise is heard, which becomes more and more evident as the movements are continued, and at the end, it may be, of half an hour, the adhesions may have so far given way as to allow of motion in all directions to a very considerable extent, in a joint which had appeared completely anchylosed." I say this is not the manner in which this operation ought to be performed. It is capable of abuse, just as is any other operation; but when it is performed as I have above described it, I do not know an operation more successful than this is in the whole range of surgery, or one more free from danger.

When the joint retains its normal external form, the adhesions are easily broken down by the hand, when the limb is properly placed in position, and the full effect of chloroform has been obtained; as you have seen in cases not alone under my care, but I believe also under the care of every surgeon of the 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 bealed, 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 subperiosteal 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