mine the presence or absence of stone. The sudden invasion, the existence of the gouty diathesis, and the absence of other causes to account for the symptoms present, mark the peculiar nature of the affection, and concur in making us suppose the disease to be of gouty nature. Being decided as to the diagnosis, what means are we to adopt to relieve the symptoms? The treatment in these cases is obvious and simple. First and most important, then, is free counter-irritation; but you must apply your counter-irritation carefully, and consider what form of counter-irritant will be best suited to the case. Blisters would be improper, because cantharidine, which is the active principle of the blister, is a direct irritant to the mucous membrane of the bladder, and would tend, therefore, rather to increase the distress. Turpentine must not be employed either, because it irritates the kidneys, and the irritation is liable to be propagated to the bladder. Mustard is the most effectual counter-irritant which we can use in these cases, and has not the disadvantage of the former remedies. Strong ammonia may likewise be used as a counter-irritant. Our next consideration must be to relieve pain, which in many cases is a most urgent symptom, and we should endeavour to effect this in the speediest and safest manner possible. If the affection be of the first form, where pus is generated, the best course to pursue is to give an opiate in some way or other. This may be done by the endermic method, by rubbing in a strong opiate liniment over the region of the bladder. Or, what is much better, and more certain in its action, the opium may be given in the form of an enema injected into the rectum. About half a drachm of laudanum, mixed with a small quantity of decoction of starch, of which not more than an ounce and a half, or two ounces, should be employed, may be gently injected into the rectum, and you will find that it acts as a sort of warm poultice, containing opium, to the bladder; and in this way all kinds of irritability of this organ may be relieved. The irritable state of the bladder caused by cantharidine (strangury) is effectually relieved in the same way, and gouty inflammation is benefited in like manner. The action of cantharidine, indeed, forms a pretty good illustration of the manner in which we may suppose the gouty poison to cause the vesical irritability, and they may both be relieved in a similar manner. If the patient is not quite relieved after the administration of the first enema, you need not be afraid to give a second, provided that you are sure he exhibits no peculiar idiosyncrasy with respect to opium. In many cases of this kind you may give opium also with advantage by the mouth, and especially in combination with sudorifics.

With reference to the treatment of all cases of gout, where the disease is apt to attack internal organs, I may give you this practical hint, and I strongly advise you to bear it in mind whenever you may be called upon to treat gout of this nature. It is this, that these cases are of an asthenic character, and do not bear depletory measures; so that if you find a patient labouring under gout of the stomach, or gout affecting the bladder, you must not think of applying leeches, and employing the treatment which would be applicable to other forms of inflammation of these organs; for the abstraction of even so small a quantity of blood as would be taken by the application of a few leeches might do the patient serious mischief, and cause prostration from which he might never rally. On this point Sir Benjamin Brodie has expressed a similar opinion; for he lays it down, that antiphlogistic treatment is inapplicable to that particular form of inflammation of the bladder which is of a gouty origin. With regard to the exhibition of colchicum, I am of opinion, that, in many cases, it is inadmissible, and, in all, it should be given with great caution and circumspection; for this so-called specific is certainly very depressing in its influence, and therefore unsuitable to cases which partake of the asthenic character.

The treatment which, in my experience, has been most beneficial for gout, when it attacks any of the hollow viscera, consists in employing free counter-irritationkeeping up a moderate action of the bowels-paying attention to the functions of the skin, and promoting the action of this great secreting surface by the exhibition of sudorifics. Provided the urine be not alkaline, the administration of alkalies will be found of service, and opium is employed with great advantage for allaying the irritability of the affected orgau, which is often productive of great distress to the patient.

As I have before hinted, there is much resemblance between the gouty affections of the bladder and those of the stomach. In the latter organ, gout shows itself by the sudden development of violent pain referred to the stomach. This is often at

tended with the generation of gas in immense quantities, which distends the organ. Another form is, when the stomach is impatient of the smallest quantity of food, as the bladder is of urine. Incessant vomiting is the characteristic symptom of this form of the complaint. Sometimes these symptoms exist together. In other cases, the muscular coat becomes greatly weakened, and the food is pushed on only very slowly into the bowel. It accumulates in and distends the stomach, which becomes dilated and large, and by reason of the atonic state of the organ remains so. In all the forms of the complaint, but in none more than in this last form, the tendency to the generation of gas is a very prominent feature.-Med. Times and Gaz., May 28, 1853, p. 539.

SURGERY.

AFFECTIONS OF THE BONES AND JOINTS.

62.-IMPROVED FRACTURE APPARATUS.

By HENRY GREENWAY, Esq., Plymouth.

[Mr. Greenway invented this apparatus while a student at King's College Hospital, and it has been favourably noticed by Mr. Fergusson in his recent work, 'Practical Surgery. Since that time, however, he has considerably improved the apparatus, which he describes as follows:]

Two tension-rods, a a, extend, one on either side, and unite in a curve at one end; on these are slides, b b*, which support two iron plates, c c*, so bent as to present two sides at right angles with the floor; the one, c, being designed for counter-extension, can be moved to any given point, and there fixed with a check-pin; the other, c*, by means of which extension is to be made, is mediately attached to a screw, d, which pierces, in a central line, the tension-rods at their point of junction. On this screw is a nut, e, by whose action against the rods the requisite extension and counter-extension forces are obtained.

Within each bent plate, c c*, are two pressure pads, one on either side, ff*, which are moved towards each other by means of a nut and screw, as shown in Fig. 2, and thus made to embrace the limb.

A back-piece, or floor, g, on which the limb is to be placed, extends nearly the whole length of the apparatus; it is fixed to the bent plate, c, but merely rests on the one c*, at the opposite end; so that, when extension is made by turning the nut e, the bent plate c* is drawn to a greater distance from the other.

FIG. 1. aa, tension-rods; bb*, one of the slides of each bent plate; cc, bent iron plates; d, a screw, on which is a nut, e, for producing extension; ff*, one of the pressure-pads of each bent plate; g,1 backpiece or floor, with pad; h, foot piece, with pad.

Connected with the bent plate c* is a movable foot-piece, h, intended only to keep the foot in a proper position, except when the fracture involves the malleoli. The back-piece and foot-piece are to be supplied, each with a separate pad, as shown in the drawing. The apparatus being suspended by four straps from an iron cradle, a swinging motion of the limb is enjoyed by the patient.

FIG. 2. One of the bent plates (c, Fig. 1) removed from the apparatus to show more completely its mechanism, and the action of the pressure-pads. bb, the slides which support it on the tension-rods; XXVIII.-10.

ff, the pressure-pads; proceeding outward from each is a screw, which passes through the side of the bent plate, and on this screw (between the pad and the plate) is a nut which, when worked against the plate, forces the pad towards its fellow.

It will thus be seen, that the chief novelty of the apparatus lies in the bent iron plates, with their pressure-pads, which afford the following advantages

1. Free circulation throughout the limb, as the popliteal space and the back of the leg are entirely free from pressure.

2. Sloughing at the heel is obviated, as it need only rest slightly on the backpiece, the ankles being almost supported by the pressure-pads.

3. The broken portions of bone, being brought into apposition, are not liable to be thrown out of place by spasmodic action of the muscles.

4. The limb, if the fracture be compound, can be dressed and exposed between the points of extension and counter-extension, without the extended state of the limb being interfered with.

The following is the mode in which a fracture should be treated when this instrument is used:-A doubled piece of sheeting, about four feet in length and nine inches wide, should be thrown across the back-piece in the space between the bent plates, and its ends allowed to hang equally on either side. A flannel roller should then be applied with some degree of firmness around the foot and ankles, and the limb afterwards placed on the back-piece, the distance between the two bent plates having been first regulated according to the length of the limb. The pressure-pads, with any extra padding which may be required, should now be firmly fixed, the one pair, f, against the side of the leg, just below the knee; the other pair, f*, a little above the ankles. An assistant should then make extension by turning the nut, e, the surgeon at the same time adjusting the broken portions of bone. That being done, the foot-piece must be placed against the sole of the foot, and be slightly bound to it by a turn or two of a bandage, merely to keep the foot in a natural position; and the ends of the sheeting before mentioned, folded up smoothly, and laid against the sides of the limb, are to be there retained by means of straps, as is usually practised in such accidents.

When a fracture involves the malleoli, the pressure-pads, f, having been brought to bear firmly on the limb, the foot-piece with its pad should be firmly attached to the sole of the foot by means of a bandage, and then fixed. Extension should next be made by turning the nut e; and the fractured portions of bone being adjusted, the pressure-pads, f*, may be brought slightly in contact with the ankles. The remaining treatment is as before described.

In some instances, it may be found necessary, if there be much swelling, to dispense with the sheeting, in order to use fomentations, &c.; but if there be little or no swelling, a many-tailed bandage may be applied from the ankles to the knee, after the fracture is adjusted.-Med. Times and Gaz., July 23, 1853, p. 99.

63.-MR. WINCHESTER'S NEW METHOD OF TREATING FRACTURES, WITH A DESCRIPTION OF A SUITABLE APPARATUS.

[This apparatus is best described in Mr. W.'s own words. He says:] My invention consists of joints of wood, metal or other suitable material, and of convenient length, which have the power of being fixed at any desired angle. By this arrangement we are enabled to take and retain the exact shape and form of any portion of the body, thereby forming a perfect model of the sound or healthy part, and consequently a complete support for the corresponding injured and diseased part. Its advantages are these:-It gives confidence and certainty to the surgeon in the treatment; and being applicable to all cases, and exceedingly portable, effects a great saving of time (especially to the country surgeon), and suffering to the patient. A full-sized splint can be folded into a space of fifteen inches by three wide, and three deep; can be carried round the waist as a belt, or in the pocket.

My objections to the splints at present in use are,-1st. That they are all, without exception, straight; and it is evident the binding a naturally curved limb to a straight splint must tend to straighten such limb. Again, they keep the patient too long in one position, producing at times considerable mischief, and even sloughing. This also

at times occurs from the injurious pressure arising from the use of screws or other contrivances for the purpose of extension. With regard to extension, I would remark, and I believe it will be admitted by most surgeons, that the difficulty arises, not so much in reducing a fracture, as in keeping the parts in apposition after reduction. With extension there must be counter-extension, which requires to be in constant operation; for if withdrawn, the apparatus becomes useless; and moreover, any straining beyond what is natural fatigues the muscles, irritates the patient, and impedes union. I object also to fixing the splint-as is in some instances doneto the bed, or a board provided for that purpose. The splint not moving with the limb, the least sinking in bed or motion of the body must alter the relative position of the ends of the bone, particularly in oblique fractures, which results in shortening. By the use of my splint all these imperfections are remedied. The exact natural length and shape being preserved, there is no necessity for extension, or chance of displacement. It affords perfect support throughout the entire shaft of the bone; the parts being retained in their original natural position, become quiescent, and nature has only to repair. It is also applicable to the upper extremity-to the spine, and, indeed, to any part of the body requiring artificial support.-Lancet, Aug. 20, 1853, p. 169.

FIG. 3 shows the straps used in the application of the splint. The size of the sound limb is taken when the splint is adjusted by means of the buckle with the lacing fastened. When applied to the injured limb, the original size is still maintained by the buckle; and should swelling occur the lacing is loosened, allowing the strap to expand by means of a piece of vulcanized India-rubber inserted. As the swelling subsides the strap goes back to its original size, and is again laced. By this means the necessity of loosening the strap is avoided.