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471 about a minute and a half, the head of the bone slipped into the acetabulum with an audible snap. The patient suffered no inconvenience beyond a trifling pain over the hip the next day, which was relieved by fomentations, and he could move his limb as well as ever. He was kept in bed till June 14th; on the 15th, without permission, he walked in the garden, ascending and descending a number of steps; and was discharged on the 17th, when he could walk strongly and well. DISLOCATION OF THE HEAD OF THE FEMUR INTO THE ISCHIATIC NOTCH, OF FOUR MONTHS’ STANDING, MUCH RELIEVED BY MANIPULATION AND FORCIBLE EXTENSION. (Under the care of Mr. SPENCER SMITH.) Moses J-, aged thirty, a short, muscular man, admitted into the above hospital August 5th, 1856. Four months ago, whilst walking by the side of a canal, he was tripped up by the tow-rope of a barge, and thrown into the water, and whilst holding on to the bank, which was faced with masonry, he was crushed between it and the barge. When pulled out of the water he was unable to rise or to move his right leg. He had surgical advice, and was told that the hip was dislocated. Attempts were made to reduce it, but he did not recover the use of his limb. He was confined to bed for seven or eight weeks, and on getting up could only use this leg slightly. He has now, however, acquired some use of it, and with the aid of a crutch can get about for a short distance. His right leg is about an inch and a quarter shorter than the left, so that his toes only can touch the ground, but he can bear most of his weight upon them, and by resting one hand upon a table or chair can support himself entirely upon the affected limb. He suffers considerable pain and inconvenience from pressure of the head of the bone upon the sciatic nerve, especially in the sitting posture. His ordinary position when standing is resting his weight partly upon his left leg, partly upon a crutch, with the right knee a little flexed, but not advanced, and the limb rotated inwards, so that the patella touches the inside of the left thigh just above the condyle. The toes do not reach the ground, the point of the great toe being directly over the first metatarso-phalangeal articulation of the opposite foot. When told to stand upright upon both feet without the aid of a crutch, he straightens his right knee, and places his toes upon the ground, about three inches from the opposite foot, on a level m ith the b:1.11 of the great toe, the whole limb being at the same time much inverted. The trochanter major is much more prominent than that of the opposite side, and further re- moved from the anterior superior spine of the ilium, occupying the depression at the back of the hip-joint, and forming a con- siderable projection there. This passes on to the gluteal region, which is much fuller than usual. There is a deep depression along the line of Poupart’s ligament, at its inner part especially. The extensor muscles are very rigid, the rectus projecting so as to form an outline over the front of the thigh. On examining the trochanter, it is felt to be much thickened, rough, and I irregular; the head and ueck of the femur can easily be de- fined passing backwards, with the head resting in the ischiatic notch. Two months ago he had a tingling sensation down the I limb, but he has not felt it lately. When the head of the femur ’, is forcibly moved in its position, a grating or snapping of bone is experienced; he feels it himself sometimes whilst walking, ’, but it causes no pain. The limb is rather wasted ; it is not so large as the opposite one. He has a great amount of move- ment at the hip ; he can extend the thigh till it nearly touches the abdomen, but flexion is somewhat impeded, and abduct and adduct the limb fairly, but rotation is quite lost. By forcible extension this extremity can be lengthened to nearly the same length as the sound one, but it returns to its present condition directly the extension is taken away. He has no in- crease of pain in any movement, and bears manipulation well. All these circumstances determined Mr. Smith to attempt to reduce the limb. This was first tried by manipulation, under chloroform, as in the other case, and kept up for half an hour. Several adhesions were broken down, and great free- dom of the limb was gained; the head of the bone was raised from its position and brought to the margin of the acetabulum, but could not be got into it. A fortnight later the pulleys were used; then the apparatus of Jeffreys, an American snr- geon, introduced into England some years since. This was used six or seven times, as the man did not suffer in the least from it, and each time a number of dense adhesions were de- stroyed ; but the head of the bone could not be lifted into its socket: it seemed as if the margin of the acetabulum had been fractured, and a deposition of osseous matter had taken place, as it was thickened and much more prominent than usuaL The result was that he gained increase of strength and of length in the limb, so that he could get his heel to the ground, and could move it almost as freely as the sound limb. When discharged, the leg was about three-quarters of an inch shorter than the other; but he could walk six or seven miles readily and without fatigue, and ascend the staircase to the top of the- building, and descend again, easily, without support. It was. Mr. Smith’s intention to have tried the effect of force applied in another manner,-viz., after having fixed the man (placed. upon the opposite side) firmly to an immovable form, the in- jured thigh was to have been elevated by a force applied per- pendicularly, whilst at the same time the limb was to have been extended. It was hoped that in this way the difficulty, felt throughout, of getting the head of the bone over the un- naturally prominent edge of the acetabulum might have been overcome. The patient left the hospital of his own will. His. case, however, so far as it went, was most satisfactory; and he would scarcely have been considered lame had he had th& patience to wait for and wear a high-heeled shoe. The case- also proved the great value of Jeffreys’ instrument (sup- plied by Messrs. Whicker and Blaise). The amount of extend- ing force which may be brought into operation by it is enor- mous ; being far greater, indeed, than the webbing and other- soft textures of the instrument are capable of supporting. KING’S COLLEGE HOSPITAL. DISLOCATION OF THE HUMERUS FORWARDS, PENETRATING THE FIBRES OF THE DELTOID MUSCLE; INEFFECTUAL ATTEMPT AT REDUCTION. (Under the care of Mr. FERGUSSON.) THIS was an example of dislocation of the humerus forwards,, the head of the bone, no doubt, being thrown on the inner side of the coracoid process, but with the complication of its per- forating the fibres of the deltoid muscle, and thus becoming buttoned to the muscle. The patient is a boy who resides in the country, and who had his left arm jammed between a wall and a cart a fortnight before admission, with a dislocation or- other injury of the shoulder. All the parts about the joint. appeared to be matted together from inflammation, and the surgeon who sent him up to town thought there might be a fracture of the scapula; but at the first glance it appeared like an uncommon example of a case in which the head of the bone- had been pushed through the deltoid muscle, as Mr. Fergusson could feel it very distinctly with his finger. The head moved in every possible direction but the right one, during an ineffec- tual attempt at reduction with the heel in the axilla. Some of the fibres of the deltoid muscle were subcutaneously divided, to permit of even greater freedom of motion, but without any avail. Mr. Fergusson believed that a portion of the capsular ligament lay between the head and the glenoid cavity, pre- cisely similar to a preparation in the museum of King’s College. The head of the bone, however, he had no doubt, was in its proper position, although tne capsular ligament was between the articulating surfaces. The boy was then sent to the wards and the result turned out as had been anticipated. Whilst on this subject, we may present another instance, at. Guy’s. ____ GUY’S HOSPITAL. DISLOCATION OF THE HUMERUS INTO THE AXILLA ; INEFFECTUAL. ATTEMPT AT REDUCTION TWO MONTHS AFTER ITS OCCURRENCE. (Under the care of Mr. COCK.) A STOUT, elderly woman, from the country, was admitted on the 13th of October, with the right shoulder dislocated into. the axilla. This dislocation had existed for two months, and she had actually gone the whole of that time without an attempt having been made to reduce it. On this oceasion, however, chloroform was given, when an effort was made to effect reduction with the heel in the axilla, but unsuccessfully. Mr. Cock then tried manipulation, and, togetherJwith Mr. Hilton, went as far as it was safe to do in a case of this kind. An air- pad was therefore applied in the axilla, and the arm bandaged to the chest by means of a broad flannel roller. This is ex- pected, in the course of a few days, to restore the head of the bone into the glenoid cavity, more especially as the bone was. shifted from its old position. Mr. Cock’had a similar case to this under his care a short time- back, in which attempts at reduction were equally ineffectual? but in the course of a week or so, with the air-pad, the head

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about a minute and a half, the head of the bone slipped intothe acetabulum with an audible snap.The patient suffered no inconvenience beyond a trifling pain

over the hip the next day, which was relieved by fomentations,and he could move his limb as well as ever. He was keptin bed till June 14th; on the 15th, without permission, hewalked in the garden, ascending and descending a number ofsteps; and was discharged on the 17th, when he could walkstrongly and well.

DISLOCATION OF THE HEAD OF THE FEMUR INTO THE ISCHIATIC

NOTCH, OF FOUR MONTHS’ STANDING, MUCH RELIEVED BYMANIPULATION AND FORCIBLE EXTENSION.

(Under the care of Mr. SPENCER SMITH.)Moses J-, aged thirty, a short, muscular man, admitted

into the above hospital August 5th, 1856. Four months ago,whilst walking by the side of a canal, he was tripped up bythe tow-rope of a barge, and thrown into the water, and whilstholding on to the bank, which was faced with masonry, hewas crushed between it and the barge. When pulled out ofthe water he was unable to rise or to move his right leg. Hehad surgical advice, and was told that the hip was dislocated.Attempts were made to reduce it, but he did not recover theuse of his limb. He was confined to bed for seven or eightweeks, and on getting up could only use this leg slightly. Hehas now, however, acquired some use of it, and with the aid ofa crutch can get about for a short distance. His right leg isabout an inch and a quarter shorter than the left, so that histoes only can touch the ground, but he can bear most of hisweight upon them, and by resting one hand upon a table orchair can support himself entirely upon the affected limb. Hesuffers considerable pain and inconvenience from pressure ofthe head of the bone upon the sciatic nerve, especially in thesitting posture. His ordinary position when standing is restinghis weight partly upon his left leg, partly upon a crutch, withthe right knee a little flexed, but not advanced, and the limbrotated inwards, so that the patella touches the inside of theleft thigh just above the condyle. The toes do not reach the

ground, the point of the great toe being directly over the firstmetatarso-phalangeal articulation of the opposite foot. Whentold to stand upright upon both feet without the aid of acrutch, he straightens his right knee, and places his toes uponthe ground, about three inches from the opposite foot, on alevel m ith the b:1.11 of the great toe, the whole limb being atthe same time much inverted. The trochanter major is muchmore prominent than that of the opposite side, and further re-moved from the anterior superior spine of the ilium, occupyingthe depression at the back of the hip-joint, and forming a con-siderable projection there. This passes on to the gluteal region,which is much fuller than usual. There is a deep depressionalong the line of Poupart’s ligament, at its inner part especially.The extensor muscles are very rigid, the rectus projecting so asto form an outline over the front of the thigh. On examiningthe trochanter, it is felt to be much thickened, rough, and

Iirregular; the head and ueck of the femur can easily be de-fined passing backwards, with the head resting in the ischiaticnotch. Two months ago he had a tingling sensation down the Ilimb, but he has not felt it lately. When the head of the femur ’,is forcibly moved in its position, a grating or snapping of boneis experienced; he feels it himself sometimes whilst walking, ’,but it causes no pain. The limb is rather wasted ; it is notso large as the opposite one. He has a great amount of move-ment at the hip ; he can extend the thigh till it nearly touchesthe abdomen, but flexion is somewhat impeded, and abductand adduct the limb fairly, but rotation is quite lost. Byforcible extension this extremity can be lengthened to nearlythe same length as the sound one, but it returns to its presentcondition directly the extension is taken away. He has no in-crease of pain in any movement, and bears manipulation well.

All these circumstances determined Mr. Smith to attemptto reduce the limb. This was first tried by manipulation,under chloroform, as in the other case, and kept up for half anhour. Several adhesions were broken down, and great free-dom of the limb was gained; the head of the bone was raisedfrom its position and brought to the margin of the acetabulum,but could not be got into it. A fortnight later the pulleyswere used; then the apparatus of Jeffreys, an American snr-geon, introduced into England some years since. This wasused six or seven times, as the man did not suffer in the leastfrom it, and each time a number of dense adhesions were de-stroyed ; but the head of the bone could not be lifted into itssocket: it seemed as if the margin of the acetabulum had beenfractured, and a deposition of osseous matter had taken place,

as it was thickened and much more prominent than usuaLThe result was that he gained increase of strength and oflength in the limb, so that he could get his heel to the ground,and could move it almost as freely as the sound limb. Whendischarged, the leg was about three-quarters of an inch shorterthan the other; but he could walk six or seven miles readilyand without fatigue, and ascend the staircase to the top of the-building, and descend again, easily, without support. It was.Mr. Smith’s intention to have tried the effect of force appliedin another manner,-viz., after having fixed the man (placed.upon the opposite side) firmly to an immovable form, the in-jured thigh was to have been elevated by a force applied per-pendicularly, whilst at the same time the limb was to havebeen extended. It was hoped that in this way the difficulty,felt throughout, of getting the head of the bone over the un-naturally prominent edge of the acetabulum might have beenovercome. The patient left the hospital of his own will. His.case, however, so far as it went, was most satisfactory; andhe would scarcely have been considered lame had he had th&patience to wait for and wear a high-heeled shoe. The case-also proved the great value of Jeffreys’ instrument (sup-plied by Messrs. Whicker and Blaise). The amount of extend-ing force which may be brought into operation by it is enor-mous ; being far greater, indeed, than the webbing and other-soft textures of the instrument are capable of supporting.

KING’S COLLEGE HOSPITAL.

DISLOCATION OF THE HUMERUS FORWARDS, PENETRATING THEFIBRES OF THE DELTOID MUSCLE; INEFFECTUAL ATTEMPT

AT REDUCTION.

(Under the care of Mr. FERGUSSON.)THIS was an example of dislocation of the humerus forwards,,

the head of the bone, no doubt, being thrown on the inner sideof the coracoid process, but with the complication of its per-forating the fibres of the deltoid muscle, and thus becomingbuttoned to the muscle. The patient is a boy who resides inthe country, and who had his left arm jammed between a walland a cart a fortnight before admission, with a dislocation or-other injury of the shoulder. All the parts about the joint.appeared to be matted together from inflammation, and thesurgeon who sent him up to town thought there might be afracture of the scapula; but at the first glance it appeared likean uncommon example of a case in which the head of the bone-had been pushed through the deltoid muscle, as Mr. Fergussoncould feel it very distinctly with his finger. The head movedin every possible direction but the right one, during an ineffec-tual attempt at reduction with the heel in the axilla. Someof the fibres of the deltoid muscle were subcutaneously divided,to permit of even greater freedom of motion, but without anyavail. Mr. Fergusson believed that a portion of the capsularligament lay between the head and the glenoid cavity, pre-cisely similar to a preparation in the museum of King’s College.The head of the bone, however, he had no doubt, was in itsproper position, although tne capsular ligament was betweenthe articulating surfaces. The boy was then sent to the wardsand the result turned out as had been anticipated.

Whilst on this subject, we may present another instance, at.Guy’s. ____

GUY’S HOSPITAL.

DISLOCATION OF THE HUMERUS INTO THE AXILLA ; INEFFECTUAL.ATTEMPT AT REDUCTION TWO MONTHS AFTER ITS OCCURRENCE.

(Under the care of Mr. COCK.)A STOUT, elderly woman, from the country, was admitted

on the 13th of October, with the right shoulder dislocated into.the axilla. This dislocation had existed for two months, andshe had actually gone the whole of that time without anattempt having been made to reduce it. On this oceasion,however, chloroform was given, when an effort was made toeffect reduction with the heel in the axilla, but unsuccessfully.Mr. Cock then tried manipulation, and, togetherJwith Mr. Hilton,went as far as it was safe to do in a case of this kind. An air-pad was therefore applied in the axilla, and the arm bandagedto the chest by means of a broad flannel roller. This is ex-pected, in the course of a few days, to restore the head of thebone into the glenoid cavity, more especially as the bone was.shifted from its old position.

Mr. Cock’had a similar case to this under his care a short time-back, in which attempts at reduction were equally ineffectual?but in the course of a week or so, with the air-pad, the head

472

of the bone became replaced in its natural situation, and thepatient left the hospital with a really useful arm.We can hardly expect that in either of these two cases the

heads of the bones would pass through the torn capsule, but wouldform themselves a new bed over the glenoid cavity, with a por-tion of the capsule between them as in Mr. Fergusson’s case,the natural action of the muscles keeping the arm in properposition. ____

ST. BARTHOLOMEW’S HOSPITAL.

RESULT OF SYME’S OPERATION OF AMPUTATION AT THE ANKLE-JOINT, PERFORMED BY A RUSSIAN SURGEON.

(Under the care of Mr. STANLEY.)PERHAPS the peculiar part of the following case is its history,

which is at the same time more or less interesting. A sailorwas admitted into St. Bartholomew’s Hospital just before the31st of October, with a painful stump left after Syme’s opera-tion of amputation at the right ankle-joint, performed at Sebas-topol by a Russian surgeon. It appears that in April last thepatient, who was a seaman on board of a collier which sailedfrom Shields, arrived at Sebastopol, the vessel having a cargoof coals for the Russian government. The sailor, with a partyof others, thought he would go and see the town of Sebastopol.As they were smoking their pipes, a spark fell upon an unex-ploded shell lying at the patient’s feet, which immediatelyburst, scattering its fragments around, and almost completelydestroying his foot. It was amputated at the ankle-joint by aRussian army surgeon. The stump healed up, and the sailorreturned to this country. He, however, had constant pain inthe cicatrix, and had no rest or comfort whatsoever.At the patient’s request, Mr. Stanley, on Oct. 31st, am-

putated the leg higher up-viz., at its lower third, underchloroform. This was, Mr. Stanley observed, a secondaryamputation, not in the sense in which that term was generallyemployed, but secondary because a primary operation had notproved effectual. No doubt the Russian surgeon was as fullyaware of the nature of Mr. Syme’s operation as any one of us;but most probably, as the foot was almost completely de-stroyed, he could not form a cushion for the end of the stumpwith the integuments forming the heel, and had therefore tocontent himself with such a covering as the nature of the caseafforded. The cicatrix was in the hollow of the stump existingbetween the malleoli; for they were not sawn off, and even ifthey had been, in the present instance it is very doubtfulwhether the stump would have been a good one, from the wantof a cushion. The man is going on well, and will have a betterstump.

CLINICAL RECORDS.

INJURIES FROM A BENGAL TIGER.

IT is a very novel circumstance to encounter a live tiger iithe streets of London, but owing to the unfastening of the doo:of a cage in which was confined a fine specimen of the Bengatiger, the animal jumped into the thoroughfare, near the dock;from which it had just been brought. It encountered a littl(

boy, said to be about ten years old, took him up by the arm irits jaws as a cat would a mouse, carried him a short distance, ancthen let him go on being struck with a crowbar. The boy was noitouched by this instrument, as was su pposed. He was taken to theLondon Hospital immediately after, (Oct. 26,) when it was foundthat the injuries were not of grave moment. The teeth of thetiger had penetrated the fleshy part of his left arm in three orfour places, and there were a few scratches about the head-nothing more-from which, of course, the most favourablerecovery could be anticipated. There is no doubt the tiger didnot altogether feel at home amongst a number of vehicles in acrowded street, and must have felt somewhat cowed; the jumpupon the boy must have been of the most feeble character, with-out the "tremendous velocity" for which this animal is so cele-brated in India, and of which Pliny speaks in his Natural History.The tiger is active, powerful, and ferocious, and is more dreadedthan the lion, because it is more insidious in its attack, andprowls about by day as well as night. The spring of a tigeron an elephant, in tiger-hunting in India, is a circumstancewhich causes considerable alarm to those in immediateproximity. Occasionally they have been injured, and Mr.Boulderson mentions that the scratch of a tiger is sometimesvenomous, as that of a cat is said to be; but those persons whohave been wounded by the teeth or claws, if not killed outright,generally recover easilv enough.

PROPOSED EXCISION OF THE KNEE-JOINT.

CASES in which severe operative measures have been contemplated and finally avoided by the substitution of milder oneaconstitute a very important class. One such, of much interest,occurred on the 26th ult., under Mr. Hutchinson’s care at thfMetropolitan Free Hospital, in which an excision at the knehad been proposed. The patient, a very delicate-lookingwoman, had been sent up to town by Dr. Dunhill, of Cran.brook, with a view to some operation-either amputation 01resection—being performed, on account of diseased knee andthigh of old standing. The history pointed exclusively to ne.crosis of the lower part of the femur having been the first mani-festation of disease. This had followed a fall some years ago,and there had been open sinuses ever since. In April last,however, the disease involved the articulation, which becameaffected by acute inflammation, attended by the usual symp-toms of ulceration of cartilage. The tibia was now partiallydislocated backwards, and a state of membranous anchylosisexisted. The patient could only move about on crutches, andsuffered severe pain on the slightest movement of the joint.With the above history it seemed fair to conclude that an open-ing existed connecting the cavity in which the necrosed bonelay embedded with the interior of the joint. Mr. Hutchinsontherefore proposed to lay open the articulation, resect the endsof the bones, and then extract the sequestrum from the femur.As a trial measure, however, it was determined to attemptthe removal of the dead bone, without in the first instanceopening the joint. A careful dissection was accordingly madeon the inner side of the bone, in the tract of a sinus which ledto the back of the bone, just above the popliteal space. Herea sequestrum of considerable size was found, very deeplyplaced and embedded in the cavity in the posterior part of thebone. With little trouble the whole of it was extracted inthin fragments, and now the channel which led down into thejoint could be easily felt. Having wholly removed so potent asource of irritation, it was determined not to further interferewith the joint. We shall watch the final result with muchinterest, but there appeais every reason to expect that, as thenecrosis was in the first irstance the cause of the joint mischief,the latter will now subside, and the poor woman will recoverwith an anchylosed but useful limb.

,

CARIES OF THE CUBOID, FOLLOWED BY SUPPURATION OF THE, KNEE; AMPUTATION.

IF anything is startling to the surgeon, it is the remarkable, supervention of very grave mischief Upon comparatively the

most trifling amount of disease. This unfortunately we oftensee verified, but lately in a very unusual degree in a youngman in the Royal Free Hospital, who some months ago wasadmitted with caries of a portion of the cuboid bone of his leftfoot, which was removed by Mr. T. Wakley, and followed atthe time by apparently the best results, for the wound, wemay say, perfectly healed up, and he left the hospital. The

patient’s constitution was, however, a very bad one, and hereturned, some weeks afterwards, with inflammation of thedeep-seated absorbents, and formation of matter along theirentire course, only stopping short at the knee-joint itself,which became filled with pus. An enormous abscess formed inthe calf of this leg, which was opened, and gave exit to pintsof matter, which flowed daily in great quantity, exhaustingthe patient to the lowest condition of life. It was deemednecessary to remove the limb, which was performed, underthe influence of chloroform, on the 24th of September, byMr. Alexander Marsden, at the lower third of the thighby the antero-postcrior flaps. Very little blood was lost,and the operation was borne very well. Since then he hasgone on very favourably, although delicate from deposit oftubercle in the apex of the left lung. For this he is takingcod-liver oil, and the most nourishing diet and wine; the

stump has now (October 19th) perfectly healed, and all theligatures have come away. On examining the limb afterremoval, the navicular, and cuneiform bones were cariousand surrounded with pus, which extended to the ankle-joint,and by means of a narrow channel communicated with thelarge abscess in the thigh, and, from the rapid tendency tospread, had involved the knee-joint. This was a case wellillustrating the contiguous spread of suppuration along theib-sorbents, and we have no doubt it would have extended up tothe hip if the thigh had not been removed. We regret to sayhe subsequently succumbed from pyaemia.DR. F. W. HEADLAND will deliver the Lettsomian Lec-

tures, at the Medical Society of London, commencing on the18th instant.