2
703 like a " Scotch mist," which may last for several successive days; whereas, in the south, it comes down in sudden and violent torrents. I have had disagreeable experience of these drizzling mists in many parts of Lombardy. Along the lake of Garda, particularly, the weather seems to be divided between stormy winds and continuous mists, and I have still a vivid recollection of the cold, clammy, creeping sensation of skin which I experienced in the vicinity of this boisterous lake, notwithstanding the pleasing descriptions of Catullus, who selected the locality for his residence. The climate and scenery along this troubled water-" fluctibus et fremitu assurgens"-very closely resemble those of a Highland loch. There are now and then snatches of clear sky and fine weather; but stormy winds and misty rains are of too frequent occurrence, either for comfort or for health. The prevailing winds of Lombardy have a frigorific ten- dency. It has been already mentioned that this plain is bounded on the north by a chain of mountains-the central Alps-and parts of the same range, which dip as they approach the Adriatic, but they are not of sufficient altitude, especially towards the eastern extremity, to protect the open plain. The south wind is partially arrested by the transverse chain of the Apennines; and the west wind, the influence of which elsewhere is to modify the extremes of heat and cold, and, as it were, to transform an intense into a moderate climate, meets with an almost insurmountable barrier in the lofty summits of the Swiss and Piedmontese Alps. When the west wind does overcome this obstacle, it has lost so much of its natural character that it cannot produce similar modifications in the climate which the same wind does along the shores of the Mediterranean. The meteoric influences of Lombardy are then decidedly cold and variable, and the action of the winds is clearly given by M. Carriere in the following summary : The west has little or no influence in this district; the south does not pre- ponderate ; the north circulates pretty freely, but the north- east still more so, for it enters the plain by the extremity of the Carpathans and of the Julian Alps, which are the lowest of the entire range of mountains that bound the Lombard plains on the north. The refrigerating influences would be still further developed if the east, the south-east, and even the south-south-east, did not blow from the Adriatic and the eastern shores of lower Italy. This anemological distribution, while it maintains a moderate or low temperature, according to the seasons, favours the formation of fogs, the accumulation of clouds, a humid state of the atmosphere, and the frequent fall of rain. The extremes of temperature increase in pro- portion as we approach the valleys at the foot of the central Alps, especially those most distant from the Adriatic coast. The relative frequency of the north-east wind, and the freedom of its action over the plains of Lombardy, materially affect the temperature. The entire coast of the Adriatic, from Venice or Trieste to Otranto and the promontory of Leucadia, is subjected to two kinds of influences, perfectly opposite in their nature and effects. Along the southern portion of this line the warm winds prevail, especially the south-east, which oppresses the invalid, and interrupts the transpiration. The northern extremity is under the dominion of the north-east. Venice, for example, enjoys a moderate temperature, rendered benign by the influence of the winds I from the Adriatic, but it is also more or less subject to the effects of the wind above mentioned, that escapes by the eastern extremity of the Julian Alps, and sweeps over the lagunes. If, however, the temperature of this singular city is lowered by the northern breeze, the climate gains, in another xespect, by the clearness and transparency which the same wind imparts to the atmosphere whenever it blows.* It is evident, from the preceding observations, that the climate of Lombardy, especially of its central portions, cannot -afford more benefit to the consumptive invalid than that of the fens of Lincolnshire, or of the marshes of Holland. The reader has now placed before him the exact conditions and agencies involved in the constitution of that climate. The results of M. Carriere’s researches corroborate in every respect my own views on the subject. The topographical, hygrometric I and anemological influences brought to bear upon the consti- tution of the climate of the plains of Lombardy show clearly enough, in my opinion, that a locality equally injurious for persons suffering from pulmonary consumption could not be found in any part of the United Kingdom, or of central Europe. The climate of the principal towns of Lombardy, such as Brescia, Pavia, Verona, Mantua, possesses the same obnoxious * Dottore Giacinto, " Delle Condizone di Venezia, in cio che risguarda la Vita e la Saluta dell’ Uomo." characters as those of the general climate of the country. Pavia, for example, which is situated in a low and damp neighbourhood near the confluence of the Ticino and the Po, is subject to frequent fogs. Dr. Webster, who was attracted to the university of that ancient city by the fame of Scarpa, Volta, and their eminent colleagues and successors, writes, in reply to my inquiry:-" That for many weeks during winter the fogs are so dense, that the sun is scarcely visible. During the whole of my residence in Pavia-from November to April-I seldom saw a clear day; indeed, for months real sun- shine was unknown. This place I consider, in many respects, a very unhealthy residence; agues, fevers, inflammations, and other severe diseases being common complaints, whilst enlargements of the spleen and liver are very frequent in hospital patients. In short, a person might as well reside in Holland as at Pavia, with this difference, that in the former country, where I have also travelled, he does not expect an agreeable climate ; whilst, throughout "La Bella Italia;’ strangers usually anticipate, although often erroneously, an Elysium, but which they will certainly not find in this district, nor in many others, however agreeable to the animal feelings and senses." Mantua is not better circumstanced as regards climate. Although the " full-spreading beech" and the groves of " thick hazles" are replaced by the batteries and fortifications, with their moats, dry and wet ditches, &c., of la brutta gente, as the Lombards contemptuously call their Austrian rulers, "marshes with slimy rushes" still remain to impregnate the air with noxious exhalations, and so favour the development of disease. Nor is Verona an exception to the general rule. Mr. B. Honan, an accurate observer, and a gentleman of authority, who has had many years’ experience of the climate from resi- ding in different parts of Italy, both north and south, writes from Verona, in the month of January of this year, in the following unmistakable ipsissima verba, which are true, gene- rally speaking, although somewhat vernacularly expressed : " There are many humbugs in Italy, but there is none against which I more complain than its climate. I never spent so severe a winter as this, and I seek in vain any one corner where I can find shelter from the dry and piercing cold. In all northern climes the houses are prepared for the severity of the weather, and with good stoves, thick carpets, well-closing doors and windows, and our bright sea-coal fire, we defy the winter; but in Italy the cold is more intense within the house than without, as not a single window or door is air-proof, and a bright fire only increases the number and bitterness of the various currents which it inhales through every chink. At the moment whilst I write I am assailed in front, in flank, and rear, and my palsied fingers can with difficulty hold the pen, though Nature has not made nie one of the shivering race; but I cannot tolerate humbug in any shape, and above all, the humbug of an Italian climate!" Writing from Rome in the middle of the following May, the same author observes:- " The weather is still cold and disagreeable, and the humbug of an Italian climate applies as much to the spring at Rome as to the winter at Verona." Half Moon-street, Piccadilly, Dec. 1850. A Mirror OF THE PRACTICE OF MEDICINE AND SURGERY IN THE HOSPITALS OF LONDON. Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, et dissectionum historias, tum aliorum proprias, collectas habere et inter se comparare.—MORGAGNI. De Sed. et Caus. Morb., lib 14. Proœmium. GUY’S HOSPITAL. Compound Dislocation of the Knee. (Under the care of Mr. BIRKETT.) WE had occasion, in a recent LANCET (p. 654), to call atten- tion to a case of spontaneous dislocation of the knee, under the care of Mr. Holt, at the Westminster Hospital. Such cases are somewhat rare when unconnected with destruction of the joint by chronic disease, but a dislocation of the knee, accompanied by a wound of the soft parts, is not only of un- common occurrence, but likewise of a very dangerous nature, for it will in general entail upon the patient either the loss of life or limb. Sir Astley Cooper says, with reference to this

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703

like a " Scotch mist," which may last for several successivedays; whereas, in the south, it comes down in sudden andviolent torrents. I have had disagreeable experience ofthese drizzling mists in many parts of Lombardy. Alongthe lake of Garda, particularly, the weather seems to bedivided between stormy winds and continuous mists, and Ihave still a vivid recollection of the cold, clammy, creepingsensation of skin which I experienced in the vicinity of thisboisterous lake, notwithstanding the pleasing descriptions ofCatullus, who selected the locality for his residence. Theclimate and scenery along this troubled water-" fluctibus etfremitu assurgens"-very closely resemble those of a Highlandloch. There are now and then snatches of clear sky and fineweather; but stormy winds and misty rains are of too frequentoccurrence, either for comfort or for health.The prevailing winds of Lombardy have a frigorific ten-

dency. It has been already mentioned that this plain is boundedon the north by a chain of mountains-the central Alps-andparts of the same range, which dip as they approach theAdriatic, but they are not of sufficient altitude, especiallytowards the eastern extremity, to protect the open plain.The south wind is partially arrested by the transverse chainof the Apennines; and the west wind, the influence of whichelsewhere is to modify the extremes of heat and cold, and, asit were, to transform an intense into a moderate climate,meets with an almost insurmountable barrier in the loftysummits of the Swiss and Piedmontese Alps. When the westwind does overcome this obstacle, it has lost so much of itsnatural character that it cannot produce similar modificationsin the climate which the same wind does along the shoresof the Mediterranean.The meteoric influences of Lombardy are then decidedly

cold and variable, and the action of the winds is clearly givenby M. Carriere in the following summary : The west haslittle or no influence in this district; the south does not pre-ponderate ; the north circulates pretty freely, but the north-east still more so, for it enters the plain by the extremity ofthe Carpathans and of the Julian Alps, which are the lowest ofthe entire range of mountains that bound the Lombard plainson the north. The refrigerating influences would be stillfurther developed if the east, the south-east, and even thesouth-south-east, did not blow from the Adriatic and theeastern shores of lower Italy. This anemological distribution,while it maintains a moderate or low temperature, accordingto the seasons, favours the formation of fogs, the accumulationof clouds, a humid state of the atmosphere, and the frequentfall of rain. The extremes of temperature increase in pro-portion as we approach the valleys at the foot of the centralAlps, especially those most distant from the Adriatic coast.The relative frequency of the north-east wind, and the

freedom of its action over the plains of Lombardy, materiallyaffect the temperature. The entire coast of the Adriatic,from Venice or Trieste to Otranto and the promontory ofLeucadia, is subjected to two kinds of influences, perfectlyopposite in their nature and effects. Along the southernportion of this line the warm winds prevail, especially thesouth-east, which oppresses the invalid, and interrupts thetranspiration. The northern extremity is under the dominionof the north-east. Venice, for example, enjoys a moderatetemperature, rendered benign by the influence of the winds Ifrom the Adriatic, but it is also more or less subject to theeffects of the wind above mentioned, that escapes by theeastern extremity of the Julian Alps, and sweeps over thelagunes. If, however, the temperature of this singular city islowered by the northern breeze, the climate gains, in anotherxespect, by the clearness and transparency which the samewind imparts to the atmosphere whenever it blows.*

It is evident, from the preceding observations, that theclimate of Lombardy, especially of its central portions, cannot-afford more benefit to the consumptive invalid than that ofthe fens of Lincolnshire, or of the marshes of Holland. Thereader has now placed before him the exact conditions andagencies involved in the constitution of that climate. Theresults of M. Carriere’s researches corroborate in every respectmy own views on the subject. The topographical, hygrometric Iand anemological influences brought to bear upon the consti-tution of the climate of the plains of Lombardy show clearlyenough, in my opinion, that a locality equally injurious forpersons suffering from pulmonary consumption could not befound in any part of the United Kingdom, or of central Europe.The climate of the principal towns of Lombardy, such as

Brescia, Pavia, Verona, Mantua, possesses the same obnoxious* Dottore Giacinto, " Delle Condizone di Venezia, in cio che risguarda

la Vita e la Saluta dell’ Uomo."

characters as those of the general climate of the country.Pavia, for example, which is situated in a low and dampneighbourhood near the confluence of the Ticino and the Po,is subject to frequent fogs. Dr. Webster, who was attractedto the university of that ancient city by the fame of Scarpa,Volta, and their eminent colleagues and successors, writes,in reply to my inquiry:-" That for many weeks during winterthe fogs are so dense, that the sun is scarcely visible. Duringthe whole of my residence in Pavia-from November toApril-I seldom saw a clear day; indeed, for months real sun-shine was unknown. This place I consider, in many respects,a very unhealthy residence; agues, fevers, inflammations, andother severe diseases being common complaints, whilstenlargements of the spleen and liver are very frequent inhospital patients. In short, a person might as well reside inHolland as at Pavia, with this difference, that in the formercountry, where I have also travelled, he does not expect anagreeable climate ; whilst, throughout "La Bella Italia;’strangers usually anticipate, although often erroneously, anElysium, but which they will certainly not find in this district,nor in many others, however agreeable to the animal feelingsand senses."Mantua is not better circumstanced as regards climate.

Although the " full-spreading beech" and the groves of " thickhazles" are replaced by the batteries and fortifications, withtheir moats, dry and wet ditches, &c., of la brutta gente, as theLombards contemptuously call their Austrian rulers, "marsheswith slimy rushes" still remain to impregnate the air withnoxious exhalations, and so favour the development of disease.Nor is Verona an exception to the general rule. Mr. B.Honan, an accurate observer, and a gentleman of authority,who has had many years’ experience of the climate from resi-ding in different parts of Italy, both north and south, writesfrom Verona, in the month of January of this year, in thefollowing unmistakable ipsissima verba, which are true, gene-rally speaking, although somewhat vernacularly expressed :" There are many humbugs in Italy, but there is none againstwhich I more complain than its climate. I never spent sosevere a winter as this, and I seek in vain any one cornerwhere I can find shelter from the dry and piercing cold. Inall northern climes the houses are prepared for the severity ofthe weather, and with good stoves, thick carpets, well-closingdoors and windows, and our bright sea-coal fire, we defy thewinter; but in Italy the cold is more intense within the housethan without, as not a single window or door is air-proof, anda bright fire only increases the number and bitterness of thevarious currents which it inhales through every chink. Atthe moment whilst I write I am assailed in front, in flank, andrear, and my palsied fingers can with difficulty hold the pen,though Nature has not made nie one of the shivering race;but I cannot tolerate humbug in any shape, and above all, thehumbug of an Italian climate!" Writing from Rome in themiddle of the following May, the same author observes:-" The weather is still cold and disagreeable, and the humbugof an Italian climate applies as much to the spring at Rome asto the winter at Verona."Half Moon-street, Piccadilly, Dec. 1850.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, etdissectionum historias, tum aliorum proprias, collectas habere et inter secomparare.—MORGAGNI. De Sed. et Caus. Morb., lib 14. Proœmium.

GUY’S HOSPITAL.

Compound Dislocation of the Knee.

(Under the care of Mr. BIRKETT.)WE had occasion, in a recent LANCET (p. 654), to call atten-tion to a case of spontaneous dislocation of the knee, under thecare of Mr. Holt, at the Westminster Hospital. Such casesare somewhat rare when unconnected with destruction of thejoint by chronic disease, but a dislocation of the knee,accompanied by a wound of the soft parts, is not only of un-common occurrence, but likewise of a very dangerous nature,for it will in general entail upon the patient either the loss oflife or limb. Sir Astley Cooper says, with reference to this

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dislocation-" I have seen only one instance, and I conclude it Itherefore to be a rare occurrence, and there are scarcely anyaccidents to which the body is liable, which, generally speaking,more imperiously demand immediate amputation, than these."(Treatise on Dislocations and Fractures.) We have muchpleasure in putting upon record a case of this kind which wastreated in the hospital where Sir Astley’s memory is still sovivid. The case was drawn up by Mr. W. C. Hills, whokindly put it at our disposal.W. W., a tall muscular man, forty-one years of age, but of

lax fibre, had always enjoyed tolerable health, and was em-ployed at a brewery in Kent. Patient was engaged in carry-ing a sack of oats up a ladder, and when about ten feet fromthe ground, he overbalanced himself, and fell backwards, withthe sack under him. From his account, which perhaps shouldbe taken with some reserve, it appears that the leg was twisted,the entire weight of the body resting on the inside of thefoot (the limb, however, was not entangled in the ladder).The patient was admitted April 19,1850, sixteen hours afterthe accident, and on examination of the limb, it was dis-covered that a compound dislocation of the left knee-jointhad taken place. The wound was about three inches in length,and extended across the popliteal space; the tibia was thrownupon the anterior surface of the condyles of the femur, theposterior aspect of these processes forming large prominencesin the popliteal space. On introducing the finger in the wound,the articular process of the external condyle could be feltdistinctly, this being the most prominent of the two; theligamentum patella was relaxed, and the patella itself restedupon the lower third of the femur. The haemorrhage waspurely venous, and the blood slightly mixed with some synovialfluid.The patient being placed under the influence of chloroform,

reduction was attempted, but the best directed efforts did notsucceed in replacing the bones in their normal relations.The principal artery of the limb was looked upon as uninjured,as the dorsalis pedis was felt to pulsate strongly, but the isuperficial veins of the limb were in a varicose state. Underthese circumstances, a consultation was held on the case, and Iit was deemed expedient that the limb should be removed. ’The patient was therefore brought into the theatre, and ’,having been again rendered insensible by chloroform, Mr.Birkett amputated the thigh at the junction of the middlewith the lower third of the femur. The haemorrhage wasvery considerable during the operation, on account of greatvenous congestion, which had gradually taken place; thevessels were then secured, and the stump dressed in the usualmanner. Secondary haemorrhage occurred about three hoursafter the amputation; one vessel more had to be taken up,and with the aid of cold water the loss of blood was arrested.Mr. Birkett made an inspection of the injured limb, whichpresented the following appearances:-The tibia rested upon the inner and anterior part of the

lower end of the femur; the crucial and external lateral liga-ments were torn from their attachments to the tibia, but theywere not otherwise lacerated; the external head of thegastrocnemius, plantaris, and popliteus muscles were torn andcompletely divided, which circumstance accounted for theexternal condyle being so prominent ; the tendon of the bicepswas found inserted as usual. The internal lateral ligamentwas slightly separated from its attachments at either end,but it was not torn across. The popliteal vessels were unin-jured ; the peroneal nerve rested in front of the externalcondyle, and was greatly on the stretch, this seeming to haveoccurred as the result of the condyle having been forcedbetween it and the posterior tibial nerve.The patient progressed most favourably for twenty-two

days, and the stump was nearly cicatrized, when he was seizedwith rigors, followed by the usual symptoms of phlebitis,(which disease was at the time prevalent in the hospital,)under which scourge he sank, twenty-seven days after ad-mission.We stated above, that Sir Astley Cooper had seen but one

case of this description: we shall just quote the appearancesof the injured joint in that case, from Sir Astley’s descrip-tion, to afford our readers an opportunity of convenientlycomparing the two lesions, which will be found to have hadvarious points of analogy, especially as regards the abnormalsituation assumed by the condyles of the femur. A materialdifference exists, however, in the results of the attempts atreduction, since the latter could not be effected in Mr,Birkett’s case; whilst, in Sir Astley’s, the dislocated bonewhen reduced, easily slipped from its place. It will likewisebe noticed, that the vessels and nerves escaped in both cases.

" The patient had fallen from the box of a mail coach, andhad severely injured his knee. A large opening was found inthe integuments, through which the external condyle pro-jected, so as to be on a level with the edges of the skin. Theos femoris was thrown behind the tibia on the outer side ofthe head of the latter, and the external condyle of the thigh-bone was dislocated backwards and outwards; the thigh-bonewas twisted outwards, and the internal condyle advanced uponthe head of the tibia. I made attempts to reduce the condyle,but it could only be effected with extreme difficulty; and thebone, directly the extension was removed, slipped into itsformer situation. The joint being freely opened by the ac-cident, the bone dislocated, and when reduced, easily slippingfrom its place, and the patient, having an irritable constitu-tion, the limb was amputated." On examining the parts, SirAstley found under the skin great extravasation of blood;the vastus internus muscle had a large aperture torn in it;the tibia projected forwards, and the patella was drawn to theouter side of the knee. Posteriorlv both heads of the gastro-cnemius were lacerated; the capsular ligament was so com-pletely torn, posteriorly, that both the condyles of the osfemoris were seen projecting through the laceration in thegastrocnemius; neither the sciatic nerve, the popliteal arteryand vein, the lateral, nor the crucial ligaments, were ruptured.(S’i7· A. Cooper on Dislocations and 1’7actures, p. 195.)The author adds: " It is probable that all compound dislo-

cations of the knee-joint will require a similar practice, unlessthe wound be so extremely small as to admit readily of itsimmediate closure and adhesion."

’, The ankle-joint is more frequently luxated than the knee;compound dislocations, in the case of the ankle, do, however,not so necessarily cause the loss of the limb as when theknee-joint has thus suffered. We recollect a case, admitted,a little time ago, under the care of Mr. South, at St. Thomas’sHospital, where a man, about thirty years of age, met, inconsequence of a fall, with a compound dislocation of the leftankle-joint. The inferior extremity of the tibia had beenforced through the soft parts on the inner side of the joint,and was protruding; the fibula was of course broken, and thewound extended from the astragalus round the external aspectof the joint, as far as the inner border of the tendo-Achillis.It did not, however, appear that a large arterial trunk hadbeen injured; and the result of the consultation was, that anattempt should be made to save the limb. Mr. Dixon there-fore sawed off about one inch of the protruding portion of thetibia; the bone was then replaced, and by proper rest andtreatment the patient recovered, with a tolerably useful leg,a limited amount of motion existing in the ankle-joint.

Another case of compound dislocation happened, a fewweeks since, in St. Thomas’s Hospital. The displacementexisted here principally in the foot, the astragalus being dis-located from the scaphoid bone, and fractured across its neck;the tibia was broken in several places towards its lower ex-tremity, but its inferior articular surface was still in normalcontact with the astragalus. The fibula was likewise frac.tured, and the soft parts were extensively lacerated, the pa-tient having met with a fall from a height. Mr. Simon madeseveral attempts at reduction, but his efforts were unsuccessful,and he was obliged to have recourse to the amputation of theleg. When the parts were examined after the operation, theyoffered a very remarkable example of complete fracture of theneck of the astragalus, with displacement of its head. Thesecond and third metatarsal bones had likewise been broken.

It is evident that the complication of a fractured tibia in thiscase was a great hindrance to the extension and manipulationnecessaryfor reduction,as it would have been difficult to securethe bones sufficiently by splints, to allow a certain amount oftraction. We cannot, however, agree with Nelaton, who, inhis Pathologie Chirurgicale, finds fault with Sir Astley Cooperfor advising such a practice. We once witnessed, in the Cityof Dublin Hospital, the reduction of a luxation of thehumerus in the axilla, where the same railway accident hadcaused the fracture of the bone in two places, as well as thatof the tibia. The humerus was firmly bandaged, secured withpasteboard splints, and the apparatus was sufficiently powerfulto allow of the extension necessary for the return of the headof the bone to the glenoid cavity. The reduction was effected,the fracture of the humerus united, the leg had some timeafterwards to be removed, and the case did well.

, Letters from Alexandria state, that towards the, beginning of November, a fever, much resembling the typhoidJ type, was reigning in that city. Several Europeans of dis-

tinction had fallen victims to the disease.’ .