semi-bent. The ring and little finger were quite insensible, and the heat of the limb appeared to be diminished.

Case 3. F., æt. 70, dislocated the head of the left humerus into the axilla, on Nov. 1st, 1825. Five weeks afterwards, M. Flaubert accomplished the reduction after two attempts. The patient immediately became affected with great constriction of the chest, a sense of suffocation, and the face became purple and injected. These symptoms were followed by an emphysematous effusion, stretching from under the clavicle, across the shoulder, to the middle of the back, where it gradually disappeared. The patient was pale, and the pulse weak, with nausea. In the left thigh and leg there was a sensation of cold and great numbness; the least touch upon the thigh caused exquisite pain. The patient was placed in bed, when she fell into a state of syncope for about an hour, on recovering from which, she complained of imperfection of vision, severe head-ache, and loss of motion in the right arm. Paralysis of the bladder, and of the upper and lower extremities of the left side, succeeded-difficulty of breathing followed after -sloughs formed upon the sacrum-and the patient died comatose on the 18th day after the reduction of the dislocation.

Dissection. The pectoralis major was bruised by the roller used for counter-extension, indeed, on the inside the fibres were reduced to a kind of reddish-brown bouillie. On the outer border of this muscle was a cavity containing bloody serum. All the nerves of the arm were united in a mass in the axilla by means of condensed cellular tissue, a circumstance apparently owing to the pressure produced by the head of the bone. On approaching the scaleni muscles, the four last nerves which go to form the axillary plexus, namely, the 6th, 7th, and 8th cervical, and 1st dorsal, were found torn from their origin in the spinal marrow! The brain and its membranes were sound. On opening the vertebral canal the dura mater was of a reddish brown. The tunica arachnoides was injected, particularly in the neck. The spinal marrow at this part presented a range of white spots, marking the place from which the roots of the nerves had been torn. The medulla at this point was thicker than natural, and of the consistence of a reddish-brown bouillie, the grey matter not being distinguishable from the white. The filaments were rather red and injected.

Case 4. A woman, æt. 45, dislocated the forearm backwards. No attempt at reduction was made till Dec. 9th, 1826, twenty-seven days after the accident, when it was attempted with the aid of seven pupils. Two such efforts were unsuccessful. The patient was then bled, and extension being made again, the ulna slipped into its place, whilst the radius which remained behind was easily pressed by the thumb into its situation. At the instant

of reduction, a diminution (étranglement) of the elbow-joint took place, whilst a projection appeared above and below it. This was accompanied with a sound like that produced by the tearing of parts, and it seemed to those present, that the muscles which surround the articulation, with all the parts excepting the skin, were rent across. A considerable swelling followed, with a disposition to continual fits of syncope, whilst no pulsation could be felt in the radial artery. The pulse, however, returned next day,

and the swelling gradually subsided. On the 26th December, she had an attack of pain in the right side of the chest, which was relieved by leeches. On the 4th Jannary she left the hospital, having tolerably free motion of the arm, none in the fore-arm, and but little mobility in the finger.

Case 5. The dislocation was that of the head of the humerus into the axilla, and had occurred fifteen days before M. Flaubert attempted its reduction. Before this could be effected, the operators were obliged to desist, in consequence of the patient's complaining of excessive pain in the wrist, with loss of motion in the hand and fore-arm, and numbness of the whole of the left lower extremity. Considerable constitutional irritation, and a severe attack of fever followed, whilst there took place, after a time, infiltration of the arm and fore-arm near the elbow, which lasted for several months. Subsequently, a slight power of flexion and extension were remarked in the fingers, but it did not increase. The fore-arm, at the time of the report, 1827, could be bent to a right angle with the arm, but there was much pain in the former, the neck, and the wrist; the whole limb, in fact, was wasted and useless.

Case 6. A man, æt. 40, received a dislocation of the left femur, the head of which rested a little above the great sciatic notch. Reduction was almost immediately effected by M. Flaubert. Two days after the accident the thigh became swollen, and the hip painful. The swelling extended to the knee, low fever was established, and on the fifth day after the operation the patient died.

Dissection. A large ecchymosis beneath the skin at the anterior and outer part of the thigh; rupture of the pyriformis, gemelli, and quadratus femoris muscles. The capsule torn, as was the ligamentum teres, close to the head of the femur. In the cavity of the joint there was a quantity of reddish pus, which communicated through the rent in the capsule with a depôt of bloody pus situated between the pectineus and adductor muscles. All the great organs were sound.

The perusal of the preceding cases will, we fear, give rise to opinions not highly favourable to the caution and judgment of M. Flaubert. An unlucky man might meet with one untoward case, but few surgeons of even the most vast experience have been visited with such a series of ugly accidents. short, we conceive there can be no doubt that M. Flaubert used unwarrantable violence.

In

M. Dupuytren seems to participate in this opinion, though the judgment of the surgeon and the critic is varnished by a faint expression of regret at the bad fortune of M. Flaubert. Indeed the results of this gentleman's operations would seem to be cleverly and discreetly adduced as a foil to the more fortunate manipulations of the Baron. However this may be, a statement of the results of operations for reduction, in thirty-three cases of old dislocations, deserves the attention of the surgical reader.

Of the thirty-three cases twenty-five were instances of dislocation of the head of the humerus in various directions-five of dislocation of the femurand three of that of the fore-arm.

Of the thirty-three dislocations

The formidable number of twenty-six are drawn from the private and the public practice of M. Dupuytren. The dislocation of most brief duration had lasted for five days, the oldest had attained the age of eighty-two, and the majority had existed for twenty, forty, and fifty days.

One of the twenty-six patients died, in consequence of enormous laceration of the soft parts surrounding the articulation produced by the teeth of an enraged horse.

One patient suffered ever afterwards from difficulty in the motions of the hands and fingers. Reduction had been effected in this instance eight days after the reception of the accident.

In one child, ten years of age, dislocation of the elbow had existed for sixty-six days, and reduction was found to be impossible.

The remainder of the twenty-six patients of the Baron were quickly and perfectly cured.

The twenty-seventh and twenty-eighth cases are taken from Dessault. One of the dislocations (of the head of the humerus) was reduced on the forty-fifth day. Emphysema supervened upon the chest, but the patient, who was sixty years of age, had recovered on the thirtieth day after the operation. The second dislocation (of the humerus also) was reduced by Dessault on the ninetieth day. The patient was a female, aged 34; she was cured on the sixty-eighth day from the operation.

The twenty-ninth and thirtieth cases are taken from a work of Mothe, a surgeon to the Hôtel Dieu of Lyons. One dislocation had existed for seventeen days, and the other for five weeks prior to reduction.

The thirty-first case occurred to M. Sanson, second surgeon of the Hôtel Dieu of Paris. The patient was a female aged fifty-five, and the dislocation was reduced on the ninety-eighth day. The patient was soon well.

The thirty-second is extracted from a Treatise on Surgery by Delamotte, and is that of a physician named Desrosiers, who met with a dislocation of the humerus, which Delamotte reduced at the end of two months.

The thirty-third case is related in the fifth volume of the Memoirs of the Academy of Surgery, and displays so much of the incredible and inaccurate, as not to deserve more particular notice. The thigh is said to have been dislocated, and to have been reduced after the expiration of two years.

A little research would extend this list from English sources. afraid of unseasonably augmenting the dimensions of this article.-Eds.

We are

M. Dupuytren relates a case, possessing some features of interest. The reporters, indeed, who magnify at every turn the genius of their chief, assert that the fact is unequalled for singularity by any in the history of medicine. Our readers may judge for themselves.

Case. An old woman presented herself in the out-patient's room at the Hôtel Dieu, with a dislocation of the head of the humerus. The accident had happened six weeks previously, from a fall upon the hand with the arm extended forwards. The symptoms on her application were evidently those of dislocation downwards, into the axilla. But she stated that the symptoms had varied in the interval between the fall and her appearance at the Hôtel Dieu; and she said she had had the power of restoring the limb to its proper place, by efforts of her own and certain motions of the shoulder. When she had done this, she could move the limb, but still a certain degree of difficulty was experienced, and on making the attempt at any thing like an extensive motion, the symptoms of dislocation reappeared.

M. Dupuytren at first disregarded this story, and proceeded in the usual manner to reduce the limb. This appeared to have been done, and the patient declared that the limb was in place, as it had been before. On making a more particular examination of the shoulder, M. Dupuytren discovered that the deltoid was still more flattened than natural, and the prominence of the acromion still too great. Extension and counter-extension were resumed, and, after some slight efforts the head of the humerus was properly lodged in the glenoid cavity.

M. Dupuytren explains the circumstance with ingenious probability. The head of the humerus had undoubtedly been dislocated into the axilla, and had probably ruptured the capsular ligament. He supposes that the patient was enabled to replace it, partly on the anterior border of the glenoid fossa, partly in the contiguous subscapular fossa—that slight motions of the arm were compatible with the presence of the head of the bone in this situation-but, that more extensive movements occasioned its displacement. These are the only observations of the Baron on dislocation of the head of the humerus, which appear to require any notice.

ON CONGENITAL DISLOCATION OF THE FEMUR.

This is the subject of a clinical lecture of forty-eight pages in length. It does not follow the preceding article, in the published volume, but we introduce it here, for the purpose of connecting the remarks on dislocations. The substance of this lecture may be found in a memoir of M. Dupuytren's in the Repertoire d'Anatomie. That memoir we noticed in the year 1827; but as the abstract we then gave was brief, though sufficient to display the author's views, and as many of our present readers are probably unacquainted with it, we think we may be excused for its reintroduction upon this occasion. It would not be just to our readers nor to the lecturer to omit all notice of this, an interesting and important lecture, and we cannot present a more complete and at the same time condensed exposition of the lecturer's views, than the following short republication will afford.

It is well known that the most frequent kind of dislocation to which the hip-joint is liable is that of the head of the femur upwards and backwards on the dorsum of the ileum. It is also well known that of this dislocation there are two varieties-the first is the result of accident-the second is consecutive, the result of scrofulous ulceration in the joint. But M. Dupuytren in the memoir now before us, proposes to add to the list a third variety of this same dislocation, which, as it is found at birth, he terms "congenital."

The signs which characterise it, are shortening of the limb-presence of the head of the femur on the dorsum ilei-prominence of the trochanter major-retraction of almost all the muscles of the upper part of the thigh towards the crest of the ileum, where they form around the head of the femur a kind of cone, the base towards the os innominatum, the apex towards the trochanter-the almost entire denudation in consequence, of the tuber ischii-the rotation of the limb inwards-the obliquity of the thigh proportioned, of course, to the age and development of the pelvis-the meagreness of the limb, out of all proportion to the trunk and upper extremities, which are really well developed-and the imperfect motions, particularly of abduction and rotation. The upper part of the trunk of persons thus affected is thrown backwards, whilst the lumbar portion of the column projects as much forwards; the pelvis is placed almost horizontally on the femurs, and the ball of the feet alone touches the ground. In walking we observe them incline the body strongly towards the limb which is to support the weight, at which moment the head of the femur of that side is seen distinctly to rise on the dorsum ilei, in consequence of the superincumbent weight and sinking of the pelvis, and then they drag painfully forwards the opposite limb, the head of the femur of which is perceived not to rise but to sink, in consequence of its own weight drawing it down. This series of phenomena then is repeated each step the patient takes, and although locomotion to him is not so painful as it appears, still he is incapable of making any thing like a long journey.

In the recumbent posture, most of the symptoms of the dislocation in a great measure disappear, in consequence, no doubt, of the relaxation of the muscles and removal of the weight of the trunk. In this position of the body the surgeon can by a slight effort elongate the limb and shorten it again, that is, he can pull the head of the femur downwards or press it again upwards to the extent of two or even three inches, according to circum

stances.

Let us look to the history of this complaint. Even at birth the prominence of the haunches, the obliquity of the femurs, &c. are perceptible, but in these cases the attention of the parents is seldom much directed to the malformation till the child begins to walk, and indeed even then its awkward efforts are attributed in general to weakness, &c. till the end of the third or fourth year, when the parent is at last convinced there must be something wrong. As the pelvis begins to be developed, (for it is a curious fact that the growth of the pelvis is never affected in these patients,) the symptoms which we have enumerated above become more marked, especially in females, and a person not acquainted with the true nature of the malady would consider it the consequence of scrophulous disease of the joint. But the previous history, the absence of all pain, swelling, abscess, fistula or No. XLII.

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