abrupt an angle at the popliteal space, there is almost sure to be more or less pressure on the popliteal vein, and then consequent oedema of the leg, and the troubles that ensue from that.

When the limb is thus laid upon the back-splint, and the foot accurately adjusted to the foot-piece, it is secured in its position by the apparatus you see here, formed of gutta-percha, with layers of flannel or of old blanket put underneath it. These were adapted by Mr. Vernon at my request when he was my house surgeon, to correct what I am sure is a source of considerable trouble in the management of fractures of the leg-the pressure consequent upon bandages encircling the limb and constricting it. They produce cedema of the whole limb, above and below the seat of fracture, and that oedema is often fraught with very evil consequences. Look carefully, therefore, to this-that there are no bandages constricting the broken limb. You will see that we never apply a bandage next to the limb, and within the splints. That is a custom of treating fractures which is sometimes adopted, but in which, when splints are used with proper pads, I can see nothing but evil. It serves no purpose to the limb itself by its compression, and it sometimes does considerable mischief by compressing veins when the limb begins to swell. It also conceals the limb from your view; whereas in every fracture that is under treatment you should, as far as possible, see not only the seat of fracture, but all the adjacent parts of the limb, and have these at all times fairly under your inspection.

Then, even when the bandages immediately surrounding the limb are left out, it is not unfrequent to bandage the foot to the foot-piece and the lower part of the back-splint, and to bandage the knee and the adjacent parts to the upper part of the back-splint. But these bandages have, in like manner, a tendency to produce cedema, especially the bandage of the knee; for if you bandage the knee close down upon a firm back-splint, and it has to lie there week after week for five or six weeks together, the result almost certainly is that, by pressure on the popliteal and saphena veins, oedema will ensue below the constricting bandage-oedema at and about the seat of fracture.

Now observe the different sorts of oedema that are apt to ensue in fractures of the leg.

First, there is that general oedema of the leg which comes on from the mere injury; harmless and subsiding of itself when the fracture is put into a proper position. Then there is the oedema which sometimes comes from these encircling bandages--an œdema more full of mischief. Another form is that in which the foot is hung too much below the level of the knee, as it is in the old apparatus sometimes employed of the double-inclined plane, where the knee hangs over an angle, and the foot hanging low down, is sure to become ædematous. And then there is another kind: that oedema which we have been observing of late, which seems to depend almost entirely upon irritation of the veins of the limb by hard edges of bandages, and consequent clotting of the blood in the veins. There is a woman in Lawrence ward who shows this kind of oedema. After the fracture of the leg had been repaired well in the ordinary apparatus, a plaster-of-Paris bandage was put on, and its edge rubbed against a part of her saphena vein. Trivial as it may seem as a cause of so much distress, this is a cause which I have now seen in several cases. At the part irritated, the blood clotted, with pain and tenderness of the vein, and the clot began to gather other clots at both its ends; and so it went on till the greater part of the saphena vein was obstructed by clots, extending by means of this thrombosis, which Mr. Callender has particularly described in our Hospital Reports. One vein after another, in these cases, becomes filled with clot, till at last a firm, solid oedema of all the parts supplied by these veins ensues-an oedema which does no harm, to be sure, to the union of the already repaired fracture, but which disables the patient from the use of the limb for some eight or ten weeks after the fracture has healed.

There are, then, these four kinds of oedema which we find associated with fractures of the lower extremity; but the dema that I wish to speak of especially is that which results from constricting bandages, whether put next

to the limb, or so as to enclose the limb and hold it down to the foot-piece and the upper part of the splint.

See what mischief this oedema does. First of all, it adds very much to the sufferings of the patient by increasing the weight and tension of the limb, and consequently increasing his restlessness also. But then, if the limb is ædematous, all its nutritive powers are impaired, and I cannot doubt that sometimes the delay of the union of fractures is due to this cause. The proper circulation through the limb is retarded by pressure upon the veins, and the whole process of repair is hindered. But there is another trouble. It is this oedema which adds to the probability of the occurrence of "sore heel," as we have to call it, in the treatment of fractures of the lower extremity. Of all the vexations interrupting the progress of a fracture, this is one of the chief, not only interrupting the progress of the fracture, but very much prolonging the time of the patient's convalescence, when, after recovery from his fracture, he gets up with a slough on his heel, or on the upper part of the os calcis. It is a thing which you should be very careful to avoid. One of the means of avoiding it is, that the back of the splint is perforated by an aperture for allowing the heel to project a little through it, so that the heel does not rest against the mere hard surface of the splint even though guarded with a pad. But another thing is that the heel should be kept from all sources of inflammation and oedema; for it is through these chiefly that the heel has a tendency to slough. If you will watch the different progress of cases of simple and compound fracture, especially of compound fractures followed by acute inflammation of the whole limb, you will see that in the one case the heel has little, while in the other it has more, tendency to slough, even though the manner of putting up be the same. Where there is inflammation, the whole nutritive processes of all the textures of the limb are very much lowered, and that not at the seat of fracture alone, but in every part of its extent. Then the heel, or anything else that is much pressed upon, is likely to slough. So with oedema. The whole nutritive power of the limb is impaired; and the heel, firmly held down, becomes excoriated or sore, and the recovery of the patient is seriously retarded.

In this apparatus, then, you see no constricting bandage encircling the limb at any part. The foot is held to the foot-piece by a layer of gutta-percha, which is placed, while soft and warm, across the whole dorsum of the foot, separated from the skin by a layer of flannel, and coming over the edges of the foot-piece, is fastened there with tape or string. The knee is held in the same manner; a layer of gutta-percha, separated from the skin by flannel, is put over it, passes beyond the edges of the side-splints, and is held in its place by two straps and buckles. Moreover, to avoid the necessity of straps or bandages around the side-splints, these are held together, not only by the gutta-percha and the straps which encircle it, but also by two transverse bands, which buckle across their lower end, and across and beyond the foot-piece. With that apparatus is fulfilled the design of having a imb held steady enough to its back-splint, without any place in which it is encircled by a bandage-without any place therefore in which any constriction is put upon its veins or other textures.

That which may seem to you as the defect of this apparatus is that there is no sufficient provision for the application of a continuous force of extension; and, for all that you see, the two fragments might here ride the one over the other, being so little held, as they may seem to be, by the layers of gutta-percha. But remember how very little there is to displace the fragments of a broken limb when once it has been put fairly into place and put at rest. As I explained to you the other day, the muscular contractions, which are supposed to be the means whereby the fragments of broken bones are displaced, cease after the first three or four days; so that if an apparatus is only so adjusted that it may keep the limb during those days from all risk of muscular contraction, there is no risk of disturbance from this cause afterwards. See in the ward, now, a man who was admitted some weeks ago with fractured patella. On his admission the fraginents of the patella were at least an inch apart. The limb was laid simply upon its back, level with

the trunk and at first it was quite infpossible to retain the fragments together, or to bring them nearly into contact. But day after day the muscles, contracted at first, gradually relaxed, and then, of themselves, and with the contraction of the adjacent textures, the two fragments of the patella came closed together-to within, at the most, a quarter of an inch. There is no risk of muscular contraction displacing the fragments of a broken bone at any time after the first three or four days. At least the case would be quite extraordinary, and require very special treatment, where such an accident would occur.-Lancet, Feb. 27, 1869, p. 287.

55.—ON THE USE OF CARBOLIC ACID IN COMPOUND FRACTURES, WOUNDS, BURNS, AND GUNSHOT WOUNDS.

By Dr. JOHN ROSE, Surgeon to the Kidderminster Infirmary.

Having used carbolic acid in numerous cases since its introduction by Professor Lister, F.R.S.,I do not hesitate to say that I look upon it as one of the most useful of modern therapeutic agents in surgical practice, and worthy of that distinguished, original, and philosophical surgeon. By its use conservative surgery has been rendered still more conservative, and a vast amount of misery, discomfort, and mutilation avoided. Since its introduction our operations have been less numerous, although accidents from machinery and other causes have been on the increase, and of almost daily occurrence. I observe that the reports from some of the London hospitals have not been quite favourable, and I think it the duty of those connected with public institutions to give it a fair trial, and report accordingly.

In recent wounds our honorary surgeons generally use lint soaked in a liniment of one part of carbolic acid to five of linseed oil. This seems to possess healing, antiseptic, anti-purulent, and even anæsthetic properties in a remarkable degree.

In burns, as Professor Pirrie remarks, "It seems to accelerate the subsidence of local symptoms, to procure rapid and perfect relief from pain, and to promote healing without suppuration.”

We have at present under treatment two cases of gunshot wounds-one of the leg, with comminuted fracture of tibia and wound of posterior tibial artery, and the other of the hand, with severe laceration and destruction of soft parts. Both cases are recovering, carbolic acid having acted admirably. I may add that we have tried the carbolic lac plaster as prepared in Glasgow according to the recipe of Mr. Lister, and have found it very useful.-Lancet, Jan. 16, 1869, p. 89.

56. ON THE TREATMENT OF VARUS.

By BERNARD E. BRODHURST, Esq., Lecturer on Orthopaedic Surgery at St. George's Hospital. The treatment of varus should commence within some few weeks of birth. Nothing is gained by delaying the operation; but, on the contrary, through delay more time is required to produce an equally successful result. From one or two months after birth is the time which should be selected for the operation.

In very slight cases the distortion may be removed by bandaging and movements of the limb; such treatment is long, however, and often it is unsatisfactory. In an ordinary case of varus the distortion cannot be removed by such means. With regard to mechanical treatment, Phillips says: "In the first degree of varus in infants, the foot may be restored without the division of tendons, and through the use of an instrument for extension only; but such treatment is both difficult of execution and occupies much time, it is often painful, and it is rarely efficacious. In every case, even the most simple, it is better to divide the tendons."

The tendons which require to be divided in talipes varus are those of the

tibialis posticus and the tibialis anticus muscles, and the tendo Achillis. And in dividing these tendons it is right to remember that, varus being a compound distortion, its removal must be effected by various stages. Thus, inversion of the foot should be first overcome, after the tendons of the tibial muscles have been divided: the distortion is thus reduced to the condition of equinus. In infantile varus the plantar fascia is seldom contracted, or so much contracted as to require division; but when it has to be divided, it should be done before the section of the tendo Achillis is effected.

In dividing the tendon to be operated on, the knife should first be passed well beneath it; and the cutting edge being then turned towards the tendon, this will be divided transversely on extending the limb. Some operators cut down upon the tendon instead of cutting upwards or towards the surface, believing this to be the simpler method. It is a mistaken notion, however, for not only is the mode which I have indicated easier to perform, but effusion of blood is spared by adopting this mode of division of tendons. If not always entirely bloodless, this operation is for the most part so; but it is difficult to avoid wounding vessels when the knife is used to cut down upon a tendon, and frequently under these circumstances the effusion of blood is not inconsiderable.

To divide the tendon of the tibialis posticus muscle, the tenotome should be passed down to the edge of the tibia, at from three-quarters of an inch to one inch above the malleolus, and the sheath of the tendon be opened freely, without enlarging the external puncture. The rounded knife may then be passed into the wound, and, guided by the edge of the bone, it may be directed beneath the tendon. In the adult the tendon being prominent and easily felt, the sharp-pointed knife may be slipped beneath the tendon immediately that the sheath has been opened; but in infants it is safer not to use a pointed knife for the division of the tendon.

The anterior tibial tendon should be divided immediately after the posterior tibial has been divided. The knife should be passed beneath the tendon from without inwards as it passes over the ankle-joint, and the puncture should be made close to the tendon, that the artery may not be divided. Occasionally, the anterior tibial is more tensely contracted than the posterior; in which case it should be divided first.

It is of real importance that the tendons now mentioned-namely, the tibial tendons and the tendo Achillis-should be completely divided, so that the restoration of the shape of the foot should proceed without hindrance. Should the tendon be transfixed, and consequently only in part divided, the treatment would be rendered, at least in a large number of cases, nugatòry.

The division of the tendo Achillis has already been spoken of; and it is, therefore, unnecessary again to allude to it. Before, however, this tendon is divided, the mechanical treatment of varus must be undertaken.

After a tendon has been divided subcutaneously, the puncture is immediately to be closed with a morsel of lint, and the limb, having been bandaged, is to be bound to a well-padded, flexible metallic splint. It is a rule which should always be observed to place the limb, atter division of the tendons, in the same position as before the operation; consequently, the splint is to be bent to the angle which the distortion represented, and bound on the inner side of the foot. When the punctures have healed-on the third or fourth day-the splint is to be removed, and one similar in kind, but longer, is to be applied on the outer side of the leg and foot. Even though a slight degree of traction alone be employed, it will be found that in the course of three days the foot will have yielded more, perhaps, than could have been expected from the amount of tension which may have been exerted. On replacing the splint the same effect will be produced, until at length the foot is fully everted."

If, in the infant, it is important, as has been already stated, to deal with talipes varus as a compound distortion, and divide the treatment into stages, it is of much greater moment to attend to this injunction when the patient is older; for, should the Achilles tendon be divided before inversion of the foot is removed, it may be impossible to bring the tarsal bones into their normal positions, and to unfold the longitudinal and transverse arches. It is there

fore the rule not to divide the tendo Achillis, whether in infantile or in adult varus, until the foot has been fully everted. Although rotation of the anterior portion of the foot may only be slight, yet the difficulty of removing it, and replacing the bones in their normal positions, would be greatly increased by dividing the tendo Achillis, and thus destroying the fixed position of the os calcis.

There have been numerous cases of talipes varus lately under treatment in the hospital, varying in age from one month to twenty and more years; and you will have observed that in all the treatment has been essentially the same -differing, however, in this, that the difficulty of removing distortion, increasing for the most part as age increases, requires different appliances for its removal. Many of you also have seen a case of congenital adult varus of forty-eight years, and in which the operation was brought to a successful issue. A straight, well-padded splint, carried to the knee on the outer side of the leg, and extending beyond the foot, is sufficient to remove inversion in a large number of instances of varus; but it is obvious that such an instrument is but ill-adapted to its purpose, and in severe deformity it is entirely inefficient. The instrument to be employed in this as in every case of distortion should be constructed in accordance with the mechanical relations of the parts to which it is to be applied, and the centres of motion should correspond as nearly as possible with the centre of motion of the articulation to be acted on. Scarpa's shoe clearly does not fulfil this desideratum. We have, however, in use in the wards of the hospital instruments for the treatment of varus which have lately been brought to a degree of perfection which was formerly unknown. Their action will be much more easily understood by observation in the wards than by description, and therefore I abstain from any description, but invite you to see them as they are applied in the wards.

The plantar fascia, when contracted, should be divided before the support of the Achilles tendon is removed from the os calcis, whether in infantile or in adult varus; otherwise the longitudinal arch of the foot can scarcely be fully expanded. It is rare, however, that the plantar fascia requires to be divided in the infant; yet occasionally the central portion of the fascia may require division, or the inner band of fascia may alone be contracted. In either case the contracted portion should be fully divided. In the adult the plantar fascia offers a serious impediment to the restoration of the shape of the foot, and always requires to be freely divided.

After the deformity has been removed, active and passive exercises of the limb, together with friction, galvanism, bathing, and other like means, must be employed, until easy if not complete power of motion is gained; for if the shape of the foot alone is restored, and the power to move it is overlooked, the patient will walk, but without elasticity and without motion at the anklejoint. Then distortion, to a slight extent at least, will recur, and the tendons will again require to be divided. Thus it is that the treatment of talipes varus consists of, in the first place, the removal of the distortion; and secondly, the restoration of the functions of the limb.-Lancet, Dec. 5, 1868, p. 720.

ORGANS OF RESPIRATION.

57.-ON THE TREATMENT OF NASAL POLYPI BY POWDERED TANNIN.

By W. M. BANKS, Esq., Liverpool.

The general practitioner is often consulted, at any rate in the first instance, in cases of nasal polypi. Now, if unwilling to perform the operation of evulsion himself, and equally unwilling to hand over his patient to an operating surgeon, I would suggest a trial of a method of destroying them, proposed by Mr. Bryant about a year ago. It is well known that nasal polypi are seldom or never single, and that, after having removed all the larger ones with the forceps or wire noose, there is too often a crop of young ones left