Dr. Vandyke Carter' designates them, "submorphous structures," which, in the presence of an animal basis, become embedded in the colloid matrix, and thus form calculous masses.

The experiments of Mr. Ord2 prove that crystalline forms, when associated with a colloid, are altered by two processes-first, by modification. of surfaces and angles; and secondly, by a corresponding rearrangement of the molecules themselves. He proved that the strength of a urate solution, with a concentration and excess of the acid supplied, controlled the form of the resulting crystals, and that uric acid, in many of its aspects, verged upon the nature of a colloid. He found that albumen exercised a more powerful influence than any other substance in producing a change of crystalline form, and a disposition to assume an agglomerated condition. Still, we find it difficult to say what is the chemical nature of the animal basis which, in the living being, causes uric acid to change its pure crystalline form to some other, more prone to agglomeration. But, judging from the experiments of Mr. Ord, we conclude that it is albuminous, and, as "mucin" is derived from these formations, probably mucin is the cement.

The general conclusions which we deduce from these experiments are, first, that albumen and the other colloids, when placed in the presence of uric acid, cause its crystals to be deposited in the shape of small, thick, sub-cuboidal bodies, without curved faces, and sometimes as dumb-bells or spheroids; secondly, that grape sugar and other crystalloids cause the acid to be thrown down in long tabulated or foliaceous crystals, with flat sides and sharp angles and edges-forms essential to the process of agglomeration into masses.

Oxalate of lime crystals are in like manner altered in form by the presence of a colloid; but it seems to be requisite that the colloid should be denser than for the same change in uric acid. This fact led Mr. Ord to draw the inference that, as small calculi which pass from the kidney in nephralgic colic are generally of the oxalic acid variety, they are doubtless formed in the recesses of the kidney, where the colloid medium is denser than in other portions of the urinary tract.

The triple phosphates are less frequently influenced by the presence of the colloids than the other varieties, and consequently they are less disposed to form spherical or agglomerated masses.

In the urine we find four groups of substances which are capable of moulding urinary salts into conglomerate masses, and thus of favoring the formation of calculi, viz., mucus, urea, coloring matter, and salts. Standing first among them is mucus, a colloid prone to decomposition, and active as a ferment in promoting putrefaction of organic substances when associated with them in solution; now "an excess of this mucus, altered in character in the urinary passages, or an effusion of albumen, fibrin, or blood, as often results from congestion of the kidney, or from irritation of the urinary tract, will furnish a colloid medium with which uric acid, the urates, or oxalates (themselves perhaps in excess), will combine in the manner before described and thus form a calculous mass."

The microscopic examinations of urinary calculi, by Dr. Vandyke Carter, sustain the views advanced by Mr. Ord, that the spheroidal forms of crystalline masses are not entirely due to the mechanical influences at

Microscopic Structure and Mode of Formation of Urinary Calculi, by H. Vandyke Carter, M.D.; London, 1873.

2 W. M. Ord, M.B., London, M.R.C.P., St. Thomas Hospital Reports, vol. i., 1870; also Medico-Chirurgical Transactions, vol. lviii., 1875.

work in their formation, and show that there has been a molecule disturbing power acting in the presence of the colloid medium; and also that the form and cohesion of the crystalloids in the formation of calculi may be accounted for by Mr. Rainey's theory of molecular coalescence in the production of shells.

From the microscopic examinations of urinary calculi by Dr. Carter, and the experiments upon urinary salts by Mr. Ord, we are led to the following conclusions: All crystals of urinary salts are modified in shape when they are deposited in a colloid medium; the animal basis of uric acid tends to produce this change; and like causes bring forth the same alterations in the crystals of the other salts. The necessary conditions favorable for the operation of molecular coalescence may at any time be brought into action; and wherever there is an excess of mucus which has been altered in character in the urinary passages, or an effusion of albumen, fibrin, or blood, from congestion of the kidneys, or from irritation along the urinary tract, we have furnished a colloid with which uric acid or the other salts will combine in the manner described. Such a state of system is found during certain fevers, inflammations, etc., where the urine becomes loaded with sediment, and the first nucleus of a gravel begins; this being accomplished, the little nucleus becomes surrounded by a thin layer of protective mucus, in which continued layers in molecular coalescence are deposited, and a calculus is formed.

We do not desire to be understood to say that calculi are accidental formations, dependent wholly upon bare physical causes, but rather that they depend for their production upon an association of hereditary influ ences with certain physical causes; and that the defects of structural development which we find in certain hereditary conditions probably produce certain elements which are formed into calculi through the agency of the colloids, these being themselves the result of such an hereditary state or condition. It seems necessary for the formation of calculi that these conditions should remain constant and unvarying for a period of weeks, months, or years, thus furnishing time for the slow growth of these concretions.

Time will not permit me to refer to the changes which take place in a calculus after the nucleus is formed in the kidney, and during its passage through the urethra and its lodgment in the bladder; I will, therefore, close with a brief notice of the geographical distribution of calculous affections in North America.

Geographical Distribution of Calculi.-Calculus is not universally found over the Western Continent, there being certain localities where it is met with much more frequently than in others; and then again there are sections where it is almost entirely unknown. The central portions of the United States have furnished more cases than any other parts, whilst the extreme Southern and Northern States rarely produce a case. Along the Gulf coast, the Canada line, and the Pacific shores, stone is very uncommon; as it is also in the Canadas, the British possessions, and Mexico.

In the United States, we find it more frequently in an area of country comprised within the boundaries of Tennessee, Kentucky, Ohio, Indiana, Missouri, Western Pennsylvania, Virginia, North Carolina, and Georgia, than elsewhere; there is also a tract of country adjacent to and including Salt Lake City, Utah, where the disease is said to be remarkably common. On the other hand, stone is comparatively infrequent in Alabama, New York, Maryland, and Illinois; whilst in New Jersey, Delaware, and the New England States, it is so rare that there are very few surgeons who have operated for stone in those States. The Warrens, of

Boston, have performed the greater number of all the operations for this affection which have been done in New England; and that number is very small when we take into consideration the density of the population, and the lapse of time since the settlement of the country. The States bordering on the Gulf of Mexico-Florida, South Alabama, Mississippi, Louisiana, and Texas-are almost entirely exempt from calculous troubles: not more than two or three cases have occurred in Florida; scarcely more in either Southern Alabama, Mississippi, or Louisiana; although in Southwestern Texas, along the Mexican line, quite a number of stone cases have occurred, and have been taken to San Antonio for treatment; but in all other sections of the State the affection appears to be remarkably infrequent. It is a strange circumstance that in the State of Minnesota calculous affections, in the form of nephralgic colic, are exceedingly frequent, whilst stone in the bladder is so very rare; yet this is true, and after a very extended correspondence with the leading physicians and surgeons of that State, I have been able to hear of only three operations for stone upon persons who have resided there. The same may be said of Arkansas, with the difference that gout and calculus are so very seldom seen that they have not been classed among the diseases of the State.

Taking into consideration the recent settlement of Iowa, and its scattered population, it is a little remarkable that stone has been met with so frequently as is shown to be the case by the number of operations reported. To this date I have been unable to gather any reliable information as to the frequency of calculous affections in the far West; but, from the data before me, I am led to infer that they are uncommon. Some few cases of stone have been operated upon at San Francisco, but it has, so far, not been ascertained whether they were of foreign or domestic origin.

In closing, it may be interesting to notice that almost the entire tract of country in which stone has been found to abound, belongs to the carboniferous and sub-carboniferous formations, in which gypsum, limestone, marble, and cretaceous deposits abound; regions the most productive of any others of the temperate zone, furnishing all the varieties of nitrogenous and non-nitrogenous materials of food, both animal and vegetable, the very kind of aliment most calculated to derange the digestive organs.

In summing together the probable causes of calculous affections, we place

I. Hereditary influences which control a diathesis.

II. Digestive troubles produced by an excess or deficiency of proper diet. III. Sedentary life, with indulgence in stimulating food, by which healthy nutrition and assimilation are altered to mal-assimilation and mal-excretion.

IV. Climatic changes, deficiency of clothing for the proper protection of the body, and an arrest of the healthy function of the dermoid tissue. V. Want of harmony between the great secreting and excreting organs the liver, skin, and kidneys-with catarrhal affections of the uropoetic viscera, which favor the formation of a colloid medium.

VI. Injuries of the spinal cord, by which a proper nervous influence over the mucous membrane of the urinary organs is lost.

VII. Foreign bodies present in the bladder, producing cystitis with its consequent muco-purulent discharge, and becoming nuclei upon which the phosphates are precipitated.

SUBCUTANEOUS DIVISION OF THE NECK OF THE THIGHBONE FOR ANCHYLOSIS AT THE HIP-JOINT.

BY

WILLIAM ADAMS, F.R.C.S.,

PRESIDENT OF THE MEDICAL SOCIETY OF LONDON, ETC.

MR. PRESIDENT AND GENTLEMEN :

THE observations which I propose to offer to-day for the consideration of the Surgical Section of the International Medical Congress, refer to the operation of subcutaneous division of the neck of the thigh-bone for anchylosis of the hip-joint, with malposition of the limb; an operation which was first performed by myself in London at the Great Northern Hospital on the first of December, 1869. I propose to refer to the experience which we have gained during the past six years, since its first performance, as far as I have been able to collect records of the cases operated upon; and to offer some observations on the mode of performing the operation, the selection of appropriate cases, and the results to be obtained as to the permanent condition of the limb, i. e., whether anchylosis in the straight position is to be the result, or whether we are to endeavor not only to rectify the deformity, but to obtain a false joint at the seat of operation with free voluntary motion of the limb.

Anchylosis of the hip-joint may result from any inflammatory affection of the joint, and formerly, or I would rather say in our own time, under the teaching of Sir Benjamin Brodie, and the generation of surgeons now just passing away, this was the result which all surgeons desired to see as the termination of hip-joint disease, as well as other joint affections. Their treatment was directed to the production of this result by longcontinued and absolute rest, with the application of straight and immovable splints. In connection with the subject of anchylosis, it is important that it should be borne in mind that its prevention in a large number of cases, and prevention is always better than cure, is due to the advance of American Surgery; and that Professor Sayre, by disproving one of the old surgical maxims of the English school, that absolute and long-continued rest, and recumbency with a long straight splint or some other form of splint to maintain absolute immobility of the joint, are essential to the cure of the disease-and by substituting his apparatus acting on the principle of maintaining motion during the treatment of the affection-has added a great practical improvement to the modern treatment of hip-joint disease.

As the result of the more severe forms of hip-joint disease, however, anchylosis must necessarily take place, unless resection has been performed, and must be regarded as the best possible compromise, and the best termination of a very formidable disease which threatened even the life of the patient, provided always that the anchylosis has taken place with the limb in a natural and useful position. In the hip-joint, the best position for the patient in which anchylosis can take place, is with the thigh slightly flexed, without any adduction or abduction of the limb;

a little shortening is easily compensated for, and the patient can sit down without much inconvenience in a chair. Anchylosis with the thigh in a perfectly straight position, i. e., so straight that, when the patient is lying on his back on the ground, there is no arching whatever of the spine in the lumbar regions, is attended with very serious inconveniences; the patient cannot sit on a chair except when resting on one buttock on the edge of the chair, the anchylosed limb being stretched out with the heel resting on the floor, and as a result of this habit, in cases of long standing, the knee-joint bends preternaturally backwards; this is increased by a habit sometimes acquired of crossing the sound leg over the anchylosed limb. This condition of straight, it might almost be called over-straight, anchylosis is rarely met with, but I have been consulted by two patients, one a married lady, and the other a gentleman about forty years of age, who suffered so much from this condition of straight anchylosis that they were both anxious to submit to the operation of divid ing the neck of the thigh-bone, if motion could be obtained, but as I was unable to promise this, and they had become habituated to the inconveniences, nothing was done. I may mention that it was not only the inability to sit on a chair, which annoyed these patients, but they told me that the bowels could only be relieved in the standing position, so that they were anxious to submit to any operation promising relief if motion could be obtained.

Anchylosis with the limb in a deformed position is, however, the condition for which surgical aid is generally sought. In the great majority of cases of anchylosis of the hip-joint, contraction of the joint with the limb in a deformed position is found to exist; in some cases, simple flexion of the thigh having occurred with very little adduction or abduction; in other cases, severe adduction with a comparatively small amount of flexion, and again, in others, the distortion will be found to depend upon flexion with abduction, or adduction, of the thigh, in about equal proportions. The inconveniences will vary according to the extent and the direction of the contraction, being greatest in those cases in which flexion and adduction are combined, so that the knee of the anchylosed limb is drawn across the opposite thigh; more especially when this occurs in females.

There can be no doubt that an urgent necessity for surgical interference exists in many of these cases, and it was in the city in which we are now assembled that the first operation, having for its object not only that of rectifying the deformity, but of obtaining motion by the estab lishment of a false joint, was performed by Dr. J. Rhea Barton in the year 1826. A large external incision was made, and, the bone sawn through between the two trochanters. The deformity was rectified, and the case proceeded favorably. It is said that useful motion was obtained, but that seven years afterwards anchylosis took place, and the man died of phthisis nine years after the operation. This proceeding, somewhat modified, was afterwards repeated by J. K. Rodgers and others, but the next operation of importance for this class of cases was one also performed by a distinguished American Surgeon, Dr. L. A. Sayre, of New York, who removed a transverse section of the femur, of elliptical form, just above the trochanter minor, by means of a chain saw, the

1

"On the Treatment of Anchylosis by the Formation of Artificial Joints," in the North American Medical and Surgical Journal, April, 1827, with further remarks in the American Journal of the Medical Seiences, vol. xxi.