elongation of the limb. Even M. Bonnet, who ascertained that liquid injected into the hip collects between the head of the femur and the bottom of the acetabulum, denies that any appreciable lengthening of the limb is caused thereby. M. Parise, however, and also M. Maisonneuve, found the limb very obviously elongated after injecting the joint, and from this and other experiments, such as introducing folds of lint into the acetabulum, &c., which it is unnecessary to dwell on, they conclude that accumulation of liquid or thickening of the structures within the joint must necessarily cause lengthening of the limb so long as the upper wall of the cotyloid cavity is intact. With respect, however, to increase in the size of the head of the femur causing lengthening of the limb, though M. Parise, on repeating Fricke's well-known experiments, found them erroneous, yet he concludes that in the rare cases in which the head of the bone is enlarged, lengthening of the limb cannot ensue, as in every known case of the kind the cotyloid cavity was proportionably enlarged also. As to the causes of real shortening of the limb without dislocation, M. Parise, on repeating Fricke's experiments, obtained results directly the reverse of those of that author, as artificial diminution of the head of the femur constantly produced shortening of the limb. The most important case, however, of true shortening without dislocation, is atrophy of the bones of the lower extremity, arising from arrest of development. This occurs very frequently, and, if overlooked, may occasion serious errors of diagnosis and prognosis; but error is avoided by measuring each limb comparatively from the great trochanter to the condyle of the femur, and from the head of the tibia to the outer ankle.

However clearly the causes of apparent alterations of the length of limb may be ascertained, still much difficulty often exists in determining the question practically. In the case of apparent elongation a satisfactory conclusion can indeed be obtained by placing the lower extremities symmetrically, and adopting the well-known method recommended by Sanson and A. Berard; but, in apparent shortening, as the diseased limb is adducted, the limbs cannot be similarly posited, for though the sound limb may be brought to the same degree of adduction as the other, yet to do so it must be either more flexed or extended; and, if more flexed, it would seem shorter; if more extended, longer by measurement than it really is. M. Parise, therefore, concludes that we can only approximate to the truth in this case by taking the mean between measurements of the limb in those two positions; while M. Bonnet maintains that the difficulty can only be overcome by restoring the affected limb to its natural position, which often requires some time and the aid of suitable apparatus. As to the symptomatic value of alterations of the length of the limb, M. Parise concludes that real shortening from atrophy of the bones is a bad symptom, not merely because the limb must remain permanently shortened, but because it indicates a bad form of disease; that apparent lengthening to the eye, resulting from abduction and flexion, indicates a large collection of liquid in the joint, which may, by protruding the head of the femur, also occasion real lengthening; and that dislocation is imminent when this elongation, after having been decided, diminishes slightly, but motion continues as difficult and painful, and the great trochanter, previously prominent, becomes still more so. When apparent shortening,

arising from adduction and flexion, exists at the commencement of morbus cox, the quantity of liquid in the joint is small, and the disease has probably commenced in the hard structures; when it succeeds apparent elongation, the capsule of the joint is probably perforated. Shortening both to the eye and by measurement, with prominence of the great trochanter, indicates dislocation; or, if the great trochanter is not prominent, erosion of the cartilages, or more or less destruction of the articular surfaces, according to the amount of shortening present.

M. Bonnet absolutely rejects resections in any of the large joints, even of the upper extremities. "They are," he says, "more fatal than amputations; and, after having been long considered one of the most brilliant conquests of modern surgery, they have now fallen into merited oblivion. I cannot even imagine any case in which resection of a large joint could be indicated." (Vol. i, p. 165.) We shall not stop to dispute or refute this sweeping condemnation, to which, indeed, we should not have adverted, were it not that, in addition to the resection of those joints, now pretty generally considered admissible, M. Bonino theoretically, and Mr. Fergusson practically (Med. Chirurg. for 1845, vol. xxviii), have recently inculcated the propriety of resecting the head of the femur in certain

cases.

We believe that all the known cases of resection of the head of the femur are referred to in M. Bonino's and Mr. Fergusson's papers. M. Bonino enumerates twelve, including one doubtful case (Kluge's); and to these we may add Mr. Fergusson's own case, and one which he has been informed, by Mr. C. Hawkins, occurred in the practice of Sir B. Brodie. Excluding Kluge's doubtful case, thirteen remain, which may be thus classed. In two cases (Oppenheim, Seutin) the operation was performed in consequence of fracture of the upper extremity of the femur by gunshot wounds. Ten were cases of disease of the hip-joint. And in one (Textor), though probably, if not certainly, the patient, a child aged 7 years, in the first instance laboured under disease of the joint, it was discovered after death that a fall at an early period of the affection had caused fracture of the neck of the femur, of the horizontal ramus of the pelvis, and of the ascending ramus of the ischium; and that those fractures, the existence of which was not suspected during life, had occasioned suppuration of the surrounding soft parts.

In appreciating the results of resection of the head of the femur in disease of the hip, the last case must clearly be left out of consideration. The two cases in which the operation was performed in consequence of gunshot wounds, do not directly bear on our present purpose, but we may say thus much respecting them, that, although they both terminated fatally, we are yet of opinion that in any similar case where the great vessels and nerves were intact and the soft parts not extensively injured, resection would be decidedly preferable to amputation at the hip, though the contrary opinion is advocated by M. Laillard (Relation Chirurg. du Siège de la citadelle d'Anvers). Of the ten patients on whom the operation was performed because of disease of the hip-joint, six recovered (White, Schlichting, Schmaltz, Heine, Vogel, Fergusson). All those patients were young, the two oldest, those of Schlichting and Mr. Fergusson, being both aged 14. The remaining four patients died (Hewson, Brodie,

Textor, two cases); they were all older than those in whom the operation succeeded, the youngest being, so far as we can make out, one of Textor's patients, aged 18.

The cause of death in the fatal cases seems to have been directly referrible to the operation but twice, that is to say, in one half of the fatal cases, and in one fifth of the whole number operated on for disease of the joint. Mr. Hewson's patient survived three months, and died from profuse suppuration, coexisting with, if not caused by, caries of the pelvis. One of Textor's patients survived fifty-four days, and died from sloughing over the sacrum, when the wound was nearly cicatrized and the upper exremity of the femur surrounded by newly deposited bone. A second of "extor's patients died in four days, and, though there was tubercular disease of the mesenteric glands, which, if known, would have contraindicated interference, yet death must be attributed to the operation, as was also, we are told, apparently the case with Sir B. Brodie's patient; but no particulars are given of this case, save that the patient was an adult; that the head of the bone was in the acetabulum at the time of the operation, and that the patient died a few days after it was performed.

The result of the operation in the successful cases was more favorable than might have been a priori anticipated. With respect to the patients of Schmaltz and Heine we are merely told that they recovered. A false joint formed and an useful limb was enjoyed by White's, Schlichting's, and Vogel's patients; and, in Mr. Fergusson's case, where 44 inches of the bone, measuring round the curve of the neck, and shaft were removed, the limb, six months after the operation, was about 2 inches shorter than its fellow, and a false articulation was evidently in process of formation at the hip.

The indication for the operation in disease of the hip-joint is the difficult part of the question. Most surgeons reject the operation, on the grounds that we cannot tell when the cotyloid cavity is implicated in the disease, in which case the operation must generally be useless. We believe that the disease most frequently, though by no means constantly, commences in the head of the femur, and that the bones of the pelvis become subsequently implicated; but, granting this, it only raises the presumption that the cotyloid cavity would be found healthy during the early period of the malady, when resection of the head of the femur would be utterly inadmissible. In all the cases of which we have any tolerably accurate account, in which the operation was performed, abscesses had opened externally, and the head of the femur could be felt denuded and isolate from the surrounding soft parts, the very stage of the disease in which the cotyloid cavity is usually implicated. But we may here mention that, though all Textor's patients died, yet the cotyloid cavity was found healthy in two of them; in the third it was diseased, and the actual cautery was applied after the surface of the bone was cut away. It is easy, however, to imagine a condition of things (we have seen it more than once) in which the diseased head of the femur, lying at the bottom of an ulcer or of a fistulous abcess, excites all the mischief of a foreign body, and in which its removal would seem to hold out the only chance of recovery. Under such circumstances, which existed in Mr. Fergusson's case, the operation may be justifiable, but it is one which, in the present state

of our knowledge, cannot be indicated or contraindicated by fixed rules everything must depend on the discretion and judgment of the surgeon, after carefully weighing all the circumstances of the particular case before him.

;

We scarcely feel it necessary to express any summary opinion as to the merits of M. Bonnet's work, after the very ample analysis we have given of its contents, the more especially as we have, for the most part, coupled that analysis with an expression of opinion respecting the author's views and practice. We shall therefore conclude this rather lengthened notice for the present; we say, for the present, inasmuch as we shall soon have occasion to return to the subject of diseases of the joints, when many matters not adverted to in this and the preceding article shall receive fitting consideration.

ART. VII.

Lectures on Pulmonary Phthisis, delivered in Jervis - street Hospital; comprehending the Pathology, Diagnosis, and Treatment of the Disease, with an Appendix. By J. T. EVANS, M.D., &c.-Dublin, 1844. 8vo, pp. 196.

THIS is a curious book in more respects than one. It is written by a member of the profession who formerly "spent the greater part of his time for some years in assisting St. John Long in his daily frictions ;" and who now proclaims that, "after twelve years of regular medical study, he does not think the time that he was thus so strongly engaged by any means misspent." (p. 131.) What this author may have gained either in an intellectual or moral point of view during the period he refers to, neither appears on the face of things, nor is stated in his work. On the other hand, he, in the page following that which contains the above declaration (p. 132), characterises his past conduct as a reckless trifling with human health and life;" whence it should follow, but we believe it does not follow, that, in the estimation of Dr. J. T. Evans, time passed in a reckless trifling with human health and life is not by any means misspent. It is highly probable that St. John Long held the same creed, until the death he had been so active in dealing unto others paralysed his arm for ever.

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The author is perfectly aware that multiplication of books is an evil; consequently, "if the present work did not contain some things which he believed to both novel and useful, it should never have been offered to the public." As the "best apology" for bringing it before the profession, the writer alludes in the preface to " some of the most important and original" views discussed in his pages. We proceed to attend him in his references to these views.

The reader is first informed that "the presence of tubercles appears, in the opinion of authors, to constitute the essence of the disease,"-a notion which Dr. Evans is earnest in proving to be hollow and erroneous. If Dr. Evans will produce evidence that one single author of repute teaches the doctrine he here ascribes to the class, we will acknowledge there is here something more than a rather worn-out artifice of gentlemen desirous

of notoriety as reformers. Does Louis teach the monstrous absurdity which he is here stigmatized as promulgating? No; he simply tells us that tubercle constitutes the anatomical character of phthisis. Does Carswell's voice give justification to that error? Far from this; it announces the blood to be diseased from the first in phthisical subjects, and this before the development of local tuberculization. Does Clark, in his practical volume, give any colour of justice to the accusation of Dr. J. T. Evans? Less than all others even; for in the state which he styles "tuberculous cachexia," a state fully evolved before the generation of pulmonary tubercle, he recognizes the physical substratum of the disease. But if Dr. J. T. Evans has less of the character of an original teacher here than he would desire to persuade the pupils of the Jervis-street Hospital, we willingly concede him the merit of perfect unconditional originality in the announcement that "tubercles exert little or no influence on the progress of phthisis!" This is something new with a vengeance. What! tubercles which lead to inflammation of the pulmonary substance, pleuritis, perforation of the pleura, pneumo-thorax, pleuritis sometimes accompanied with agonizing pain, in itself capable of shortening existence, -tubercles which block up and render useless or actually destroy (it may be) three quarters of the entire pulmonary substance,—which cause a reduction pro tanto of the oxygenating surface for the vivification of the blood,-which are followed by the obliteration of much of the old, and the generation of a new, vascular system in the lung,-which lead to the development of similar tubercles in the meninges, a development that may cut off individuals in a few days,-which cause ulceration of the intestinal surfaces, ulceration that by its very cure sometimes destroys life, and by its propagation renders existence torture,-what! tubercles, which do all this, exert no influence on the progress of phthisis! Verily, there is novelty and genius here; and when Dr. Evans proves his thesis, none but persons, in whom jealousy knows no limit, will dream of contesting his right to an excessively capacious niche in the Temple of Fame.

The next discovery made by the author is that "morbid anatomy is not pathology," a novelty absolutely of the first water, and which is about of the same character as the following:- healthy anatomy is not physiology: whereof we make Dr. Evans free gift for his next course of lectures in Jervis-street.

Dr. Evans objects to the division of the disease into two stages, as totally insufficient; and has divided the disease into several stages, corresponding to what he believes to be the progress of the lesions,"—a word, by the way, not English in the Gallic sense in which it is here employed. The proceeding seems somewhat inconsistent for a person who regards the main of these lesions, namely, tuberculous matter, as a matter of no consequence. But aliquando bonus Homerus-and why should not Dr. J. T. Evans be entitled to his occasional snooze?

The next novelty is the reference of several of the ordinary symptoms of phthisis, "especially those of impeded circulation, to the condition of induration, the result, as I believe, of chronic pneumonia, which so frequently takes place in the neighbourhood of tubercular masses or of cavities." Heaven help our ignorance; we had fancied that, since Dr. Carswell demonstrated the connexion of the said impeded circulation and