muscles always followed the operation. In several cases pains increasing on pressure were complained of on the anterior surface of the epiphysis of the tibia. We do not hesitate to ascribe these to violent contusions to which the part is exposed in attempting to detach the anchylosed patella. They were most marked in those cases where this detachment was attended with the greatest difficulties.

The after treatment is based on two indications: the first, to preserve the degree of extension obtained; the second, to endeavour to restore the normal functions of the joint. After forced extension has been practised, the muscles have a decided tendency to return to their former condition. We have seen, that muscles which have been contracted during a space of ten years, are not exempt from this tendency, —a fact which sufficiently refutes the opinion of those who assert that muscles under prolonged contraction utterly lose their vitality. Pathological anatomy teaches us the comparative rarity of total degeneration of the muscular fibre. It is worthy of remark, that, in a few cases of recent date, where we cannot admit of a total degeneration having ensued, the tendency to recontraction was very inconsiderable; so that a pasteboard splint, fastened by a common roller in the fossa poplitea, was sufficient to maintain the extension. In most cases, this is not sufficient, and we have then either to have recourse to a bandage of gutta percha, or, to what is better still, Stromeyer's apparatus for the extension of the knee-joint,—an apparatus which, in the further treatment, is as indispensable as it is efficacious. Sometimes the machine, which must always be applied during the narcosis in the degree of extension obtained during the operation, is tolerated for several days, unattended with severe pain. In most cases it is not possible to maintain the perfect extension of the joint for any length of time after the operation. The violent pains, attended by spasmodic contractions; the acute sensibility of those parts of the articular surfaces, so long unaccustomed to mutual contact, usually compel us to relax the machine, in order to allow the joints to re-assume a greater or less degree of flexion. The loosening of the knee-cap alone is often sufficient to afford relief. In some cases it was necessary entirely ro remove the apparatus; the degree of flexion which existed before the operation then soon returns. In the course of twelve or twentyfour hours, the pain in the muscles and the joint generally subsides so as to allow the extension by means of the machine to be recommenced. If the first operation did not succeed in producing perfect extension, and if the still existing adhesions rendered its consummation by means of the gradual force of the machine impossible, Mr. Langenbeck is wont, after the lapse of two or three weeks, to repeat the forced extension by means of chloroform. By this second operation, the extension is usually rendered perfect. In some cases an obstinate recontraction of the muscles alone demands their repeated distension in the narcosis. The re-action, after this second operation, is generally less considerable than after the first. We have seen

cases where the patient walked about with the machine free from pain two days afterwards. Where a subluxation of the tibia backwards existed, the apparatus of Bonnet for extension of the knee-joint was applied with obvious success. In the two cases where the luxation was perfect, and in others where it was very considerable, all attempts at reposition proved in vain.

Mr. Langenbeck has expressed it as his opinion, that the subcutaneous division of the two lateral ligaments might be of some service in these seemingly hopeless cases. Where a considerable degree of abduction prevailed, which, if existing together with the flexion of the tibia, always becomes more marked after the extension has been effected, an apparatus combining the mechanism of Stromeyer's machine for the extension of the knee-joint with that generally in use for the treatment of the genu vulgum, will be found of considerable service.

Should an evident contraction of the external lateral ligament be present, a subcutaneous division which we have several times seen practised with eminent success by Mr. Langenbeck, in the treatment of genu vulgum, is here advisable. In those cases where large defect in the articular surfaces of the external condyles of the tibia or femur exist, every treatment directed against the abduction will of course prove ineffectual. Those conversant with pathological anatomy will remember cases of this nature, where the external condyle of the femur rests in a deep hollow of the caput tibiæ. A fortnight or three weeks after the operation,-often sooner,-the patients wearing the machine are able, with the assistance of a stick or crutch, to walk about the room, and after some time, without either, if there is no luxation of

the tibia backwards, no defects of the inferior and posterior parts of the condyli femoris, which will always favour the re-development of the muscular contraction; and if the extremity has not become too weakened by long disuse, the machine may also be omitted.-Med. Times and Gazette, August 6, 1853, p. 134.

72.-OPERATION FOR KNOCK-KNEES.

[In the proceedings of the Medical Society of Würzburg, DR. MAYER of the Orthopædic Hospital reports the following case.]

John H, a strong and healthy-looking boy of fifteen, son of a baker, and employed in his father's business, was found, on admission into the Orthopedic Hospital at Würzburg, to have the right leg diverging about seven inches, and the left about eight, from the direction of the corresponding thigh, as seen in the first figure of the accompanying sketch.

Fig. I.

Fig. II.

On the 14th of August, 1851, the lad having been put under the influence of chloroform, Dr. Mayer made an incision beginning three-quarters of an inch below the insertion of the ligamentum patellæ, and curving downwards so as nearly to surround the front and inner (or mesial) side of the head of the tibia. He then turned the flap upwards, and divided the periosteum in the line of the first incision, and afterwards with Heine's cutting-needle separated the periosteum from the outer and posterior surface of the tibia, so as to prepare for the use of the saw. To protect the soft parts in that situation during the sawing, a strip of watch-spring, about half an inch wide, was introduced between the denuded bone and the periosteum. Dr. Mayer then, with a round saw, made two incisions converging towards the posterior part of the tibia, and meeting about a line and a half from the surface, without therefore quite cutting the bone in two. The wedge thus excised was about five lines thick at its base, and was easily removed by the forceps. The wound was cleared of bone-dust by forcible injections of cold water, after which, through the flexibility of the remaining isthmus of the tibia and the mobility of the fibula, no difficulty was found in bringing the cut surfaces of bone into close apposition. The outer wound was brought together with the greatest accuracy by needles and ligatures (as for hare-lip), the hemorrhage being quite inconsiderable. The leg was then put into one of Boyer's hollow splints, used for fracture of the patella.

Half an hour after the operation, as through the perfect apposition of the divided parts no discharge of any kind was visible, the wound was covered with a thick layer of collodion, and upon this drying the ligatures and needles were removed. The traumatic reaction was very slight, and on the fourth day the external wound (five inches long) had perfectly united. The leg was now left quiet in the splint for twenty-three days, when Dr. Mayer had the pleasure of finding that the incised surfaces of bone had united also. The next day the patient was allowed to walk in his room with crutches, and a few days afterwards in the garden without any artificial support whatever.

On the 3rd of October the other leg was operated on in the same manner and

with the same success.

He left the hospital, free from deformity, and with a firm and natural gait, on the 19th of November.-Lancet, June 18, 1853, p. 557.

73.-ON DISEASES OF THE SPINE.

By SAMUEL SOLLY, Esq., F.R.S.

[The diseases to which Mr. Solly particularly alludes commence in the ligaments of the spine, either from cold or by direct injuries, as a blow or fall. The first case is from the notes of Mr. Blake. The patient had worked at a gas factory, and was admitted into St. Thomas's Hospital, Oct. 26, 1852.]

"Exposed much to heat and cold, but enjoyed good health till fourteen weeks ago. About that time, noticed a severe catching pain in the right loin upon attempting to lift the iron scoop used in his employment; lasted about two days; was under treatment, and got better. Subsequently, the body became covered with a thick rash, with formication over the arms, trunk, and front of the legs, but without loss of power. Had diarrhoea and pain in the abdomen; was under treatment six weeks, and recovered. Returned to work on a Monday, but, not being strong enough to keep on, did not return again till the following Friday, but obliged to give up after two nights' work, on account of weakness. Remained at home for about a fortnight; at the expiration of that time, while walking, had a severe pain in the back just between the shoulders. The same night, this pain in the back continuing, he noticed a severe tingling in the left shoulder and along the side of the arm and forearm, followed by numbness. Applied a mustard poultice to the back and forearm; found afterwards that he had very little use in the arm, and no relief from pain; was cupped, and applied a liniment, but without any beneficial result; also tried continuous poultices for a fortnight, without relief. Cannot rest upon the shoulder without pain and uneasiness.”

The deduction which I make from this history is, that, in the first instance, this man was attacked with rheumatic inflammation of the ligaments of the lower cervical portion of the spine, extending from thence to the theca vertebralis, accompanied by some effusion on the cord. The severe catching pain in the right arm, on attempting to move his scoop, is not characteristic of simple rheumatic affection of the muscles. This pain is followed by a severe tingling down the arm. Now, I need only remind you of what takes place if you strike the ulna nerve, as it runs over the inner condyle of the humerus, or, in ordinary language, the funny-bone. The tingling is succeeded by numbness; in other words, the nerve which was first only irritated, is now compressed and partially paralysed. I dare say that most of you know the sensation of numbness which results if you go to sleep in your chair, overdone by your nocturnal studies, with one leg crossed over the other. When you awake, you find your leg still asleep; it is numbed from the pressure of the popliteal nerve on one side by the knee of the other leg. But, to return to the

case.

Oct. 28. Treatmet: Hydr. iodidi gr. i. ter die; moxa to side of spine.

Nov. 6. Mouth a little affected; pain and uneasiness less on lying on right side; still continues on the left shoulder. Pil. bis in die.

8th. Gums very tender. Pil. omitted.

17th. Much better. Only complains of numbness along forearm and two last fingers.

29th. All pain and uneasiness left him.

Dec. 4th. Cured.

If this man had not been actively treated, both before his admission by Mr. Else, who kindly sent the man up here, and had not this, too, been followed up, on his admission, by complete salivation, he would have had ultimately more advanced disease of the cord, and, in all probability, entire paralysis. Under the continued use of mercury, and steady counter-irritation, the deposit has been absorbed, and the poor fellow restored to health.

[Although in our large hospitals we frequently meet with cases in which the lower half is paralysed from fractured vertebræ from a fall from some great height, in which state the patient lingers rarely above some days, we do not often find in

such institutions cases of slighter injury, perhaps little attended to, but which may be the first step to serious consequences in after life. Mr. Solly records an interesting case of this kind.]

The subject of it was a fine young man, about 23 years of age. About two years and a half previous to his consulting me (on the 4th of September, 1852), he fell from a height of sixteen or seventeen feet, with his back flat on a hard gravel walk. He was stunned at the time, though he did not strike his head directly. He received immediately the best advice, was bled from the arm, and leeched over the left hip. He was very sore, and had severe headaches for some days afterwards, and was not able to walk until seven or eight weeks had elapsed from the time of the injury. He was then examined by several medical men, and pronounced sound. After this, he went abroad, and lived rather freely. Just ten months before he consulted me, he began to suffer from involuntary seminal emissions, accompanied with great feeling of weakness in the back. About two months after these first appeared, he remembers finding a swelling on the left side of the loins; but this inconvenienced him so little, that he did not even mention it to his medical attendant, who treated him for dyspepsia, ordering him plenty of horse and pedestrian exercise, with tonics; but he continued to get worse, and was obliged to return to England. On his arrival, he applied to an eminent surgeon, who treated him for the spermatorrhoea with the caustic catheter. He remained under his treatment for two months, but without improvement, when his father brought him to me. From the history which I elicited, by a careful cross-examination, I came to the conclusion that the spermatorrhoea had a spinal, not generative origin. On stripping him, I found an elongated swelling, about four inches in length, on the left side of the lumbar vertebræ. did not fluctuate, but it was elastic.

It

On rapping the spine in this situation he suffered a distinct, though not severe, thrilling pain, shooting from the spine down the legs, with some numbness. He now stated, that he occasionally suffered from the same kind of pain when walking or riding, and from the motion of a railway carriage. He also complained of a feeling of weakness in both legs, but more especially in the right. I was also informed, that he slightly dragged that leg in walking, and that he could not balance himself naturally. His countenance was anxious, and he looked out of health. The nocturnal emissions were occurring frequently, without erection or pleasurable sensations. I found spermatozoa in his urine, on examination under the microscope.

Putting all these facts together, I came to the conclusion, that the spine had been injured by the blow from his fall about two years and a half previously. I was rather afraid, from the swelling in the mass of the erector spinæ muscles, that an abscess was forming in that situation, and that the disease was not limited to the ligaments. Nevertheless, I had great hopes that it was not so serious as that, inasmuch as he bore firm pressure and rapping on the spine too well for there to be much serious disease of the bones; but I had no doubt of there being chronic inflammation, with some deposit of the ligaments of the vertebræ, and also of the theca vertebralis.

With this view of the pathology of the case, I ordered him to be confined to the house, and almost entirely to the sofa, to have a large moxa made over the swelling, to take quinine, in doses of two grains ter in die, in the infusion of roses, with sulphate of magnesia. To remain quietly in the country; scarcely move off the sofa; on no account to ride, either on horseback or in any kind of carriage, railway, or otherwise; to have meat, but not to take any wine or beer.

On the 24th of September I changed this to the carbonate of iron in ten grain doses, with pil. aloes c. myrrh. at night.

On the 22nd of October, 1852, about six weeks from his consulting me, I received the following from his medical attendant in the country:

"I am glad to say the V. T. is going on as favourably as when you saw him. The issue discharges well. He has not any numbness on tapping the spine, or any disagreeable sensation. He has had several seminal emissions, but they have been attended with natural feelings, and have not left him in the weak, nervous state as when they occurred some months ago. When I saw him yesterday, he complained of being weaker in the right leg than in the left, but not in any pain." From this date he gradually but steadily improved-the issue was healed on the 4th of December, and now (January, 1853) is quite restored to health; the swellin

has been entirely absorbed, and on both sides the loins are exactly the same size and shape. The nocturnal emissions have ceased; the urine is free from spermatozoa. Feb. 7. He has all the appearance of health, and, though still nervous about a relapse, he has no single sign indicating it.

He can bear any tapping on the spine from the top to the bottom. He has been out with his gun for several hours during the day, and feels no weakness or unnatural sensation in the lower extremities.

The result of this case is highly satisfactory, and it must encourage you to pursue a similar plan of treatment in a case in which the pathology is similar; for I do not exaggerate when I say, that, if this disease had been further neglected, it must have terminated in complete paralysis of the lower extremities.

You must not confound this class of cases with another, and that of a wholly different origin, and in which the pathological condition is likewise different. I refer to a form of paraplegia, which comes on so insidiously that the sad victim of it is almost lost before he is aware that his health is seriously deranged. The disease is unaccompanied with pain, and it generally occurs to those whose attention is so drawn from themselves by active mental exertion that they often pay no attention to the first symptoms of disease, regarding them as trivial and unimportant. The cases we have just been analysing had both an inflammatory origin; the cases to which I now direct your attention, are, I believe, anæmic from the first; they are cases of permanent spinal exhaustion, and you will see, therefore, the importance of a correct diagnosis, as the treatment which, in the one case, would cure your patient, in the other, would aggravate his malady.

The disease commences with slight numbness of the lower extremities; this is followed by some loss of power; there is no pain in the spinal region at all; when you examine them, you may rap the spine, from the neck to the rump, and the patient does not shrink. You may apply the hot sponge, but this elicits no evidence of disease of the vertebral column.

The history will assist you if you strike the right key. You find no evidence of your patient having ever received any injury to the spine. He cannot account for it at all. If, however, you ask him whether he has had much sexual intercourse, he will say, if he is honest, yes; but more probably he will not acknowledge to it immediately, but when you tax him directly with not having been satisfied with the caresses and charms of one siren, but that two claimed him for their own, and that his animal pride would not allow him to stint them, he will generally acknowledge to the truth of the soft impeachment. If, on the other hand, he says indignantly, that he never had connexion with a woman in his life, it is almost certain that he is the victim of that dread delusion-masturbation.

In the treatment of these cases you must avoid all antiphlogistic measures, for they only do harm. The first thing is to stop the exciting cause, and this is often, strange as it may seem, the most difficult part of your task.

I have known men of sound sense on all other matters, men whose judgment is of the greatest value to their clients, such slaves to the venereal appetite and their own ideas of pleasure, that they would submit to any plan of treatment that you like to propose, yet would not abstain from copulation, or give up their ordinary exercise and mental employment. I remember once saying to a patient, who consulted me for this malady, and whom I found perfectly deaf to all my advice on this point, "The best thing that could happen to you would be to be pitched out of your phaeton, and to have a bad compound fracture of the leg, which would confine you to your bed and your back for at least two months." Now, it did so happen, that this gentleman met with an accident, though unfortunately for him not so serious as to confine him for more than a month or six weeks; but even this did him so much good, and he rose so much better, that he forgot all his good resolutions, pursued the same course again, and is now perfectly, and I fear irrecoverably, paraplegic.

Unless these cases are treated very early, you can do little or nothing with them. Rest, bodily, mentally, and erotically, is the most important point; and if your patient will not submit to rest, entire rest, you had much better take your leave without prescribing; for all the medicine in the Pharmacopoeia will do no good without the rest.

As regards medicine, I have found, and it was first mentioned to me by my kind friend Sir Benjamin Brodie, small doses of the tinct. lyttæ, ten to fifteen drops, with