these troublesome consequences are, we suspect, always owing to the outer wound having been made too large, and the air having thereby been permitted

to enter.

"That such is the case is surely sufficiently proved by the success which has attended my operations. I have now performed the subcutaneous section of different tendons and muscles in upwards of 500 cases; and in not one instance have any troublesome inflammation of the wound supervened."

The great object, therefore, of the surgeon should be to prevent the entrance of the external air into the wound.

"From all these circumstances," continues M. Guerin, "I infer that subcutaneous wounds so quickly heal in consequence of the exclusion of the external air; and that it is from this fluid (the air) neither physically obstructing the circulation, nor chemically modifying the properties of the blood, nor altering in any degree its vital constitution, as well as from its not exerting any hurtful influence on the nerves and other parts which are protected from it, that the lacerated or divided tissues coalesce and unite by the first intention without any of the usual inflammatory symptoms."

That there is much truth in this observation is apparent from the surprising rapidity with which extensive effusions of blood are absorbed, and laceration of the soft tissues after some dislocations and bruises are healed, when there is no outward wound communicating with the seat of the injury. The great source of danger in compound fractures and dislocations is doubtless in the exposure of the lacerated parts to the action of the atmosphere. The dangerous effects of the admission of the air into the sacs of large abscesses is also well known to every surgeon.

Postscript.-The principle of subcutaneous division may be advantageously applied to other operations, besides that of the section of contracted muscles and tendons in cases of deformity.

In a recent number of the Gazette Medicale, we observe that M. Barthelemy, surgeon of the Hospital Gros Caillou at Paris, has strongly recommended this method of dividing synovial tumors. He slides a longish narrow-bladed scalpel under the integuments, and cuts the tumor fairly across in the middle, so that all its contents must be extravasated into the surrounding cellular tissue; the knife is then withdrawn by the small puncture, and firm compression is made on the part for a few days.

M. Barthelemy mentions three cases in which this mode of treatment has been quite successfully adopted. He suggests also, that perhaps other kinds of tumor may be advantageously treated in the same manner.

M. Malgaigne also has adopted in one case, where there were several ganglions or synovial swellings over different joints, the method of dividing the tumors fairly across from side to side under the integuments. He suggests its applicability to the treatment of some cases of hydrocele.-Gazette Medicale.

M. GUERIN ON CLUB-FOOT, WRYNECK, &c. &c.

In a lecture which this gentleman recently gave of the results of his clinical practice, during a period of three months, in the treatment of various sorts of deformity, he thus explains his views as to the primary cause of club-foot, and of congenital irregularities of the joints, as well as of some kinds of deformity affecting the spine.

This cause, in his opinion, is the contraction, acting unequally and irregularly, of the muscles of the part.

"All congenital articular deformities are, like club-foot, the effects of con

vulsive muscular contraction; and the various sorts of these deformities are the results of the combinations of this contraction differently distributed in the muscles of the trunk and of the limbs."

In confirmation of the truth of this opinion, he alludes to the state of the muscles of the calf in cases of club-foot; they are hard, unyielding, and as it were, matted together; the tendons are stiff and projecting, and so tense as to resist all attempts to restore the joint to its right position. The muscles chiefly affected in club-foot vary in the different varieties of this deformity. Thus when the foot is twisted outwardly, the tibiales, anticus and posticus, are the most contracted; when it is turned inwardly, the tibialis posticus, the adductor, and the flexor pollicis are at fault; in cases of valgus with abduction of the foot, the interior and lateral peronei are chiefly affected; and in complex club-foot, the extensors and the flexors of the toes are all more or less unnaturally contracted. In addition to the irregular contraction of certain muscles, there is in some cases, at the same time, a greater or less degree of partial paralysis.

The following table will indicate, in a certain degree, the comparative frequency with which different muscles of the leg are apt to be affected in clubfoot:

In 17 cases, the tendo Achillis was divided.

"You thus see, gentlemen, that the tendons of every muscle of the leg, with the exception of the lateral peronei,* have been divided. Conformably to our principles, we have attacked every variety of the deformity, by the section of the tendon or tendons producing it. In no one instance have we failed: you have seen successively disappear the different elements of each deformity by the practice that has been pursued. Where my predecessors were satisfied with restoring the normal direction of the foot by the division of the tendo Achillis, we have labored to effect the complete restoration of its forms, the removal of the curvatures of the plantar arch, of the forced abduction of the foot, of its curvatures inwards, of the subluxation of the toes, and of the twisted position of the foot-elements, the cause and mechanism of whose production were quite misunderstood, and the proper treatment of which had been quite overlooked."

M. Guerin next alludes to the various auxiliary means, such as manipulations, bandages, plaster of Paris moulds, and machines, used in the treatment of club-foot and other such like deformities.

He admits that each of them is respectively useful in certain cases. By well applied manipulations, after the contracted tendon or tendons have been divided, the foot may sometimes be at once restored to its right position almost as speedily as when a dislocation is reduced. When, however, the resistance is

These muscles were divided in a case which occurred subsequently to the delivery of the lecture.

means.

much greater, then recourse must be had to bandages, instruments, and plaster moulds. M. Guerin speaks in terms of high praise of the last named "When the deformity has been very great, and the resistance is so decided as to prevent the adjustment of the limb either with the hand alone, or with the aid of instruments, (after the section of the contracted tendons) or when the skin is so tender that a sufficient degree of mechanical compression cannot be employed without risk or injury, then the plaster mould, by distributing an equal amount of pressure on every point of the limb, and by retaining and concentrating on its surface the cutaneous exhalation, is by far the best means for overcoming the resistance, and repairing any injury to the integuments which may have been caused by the use of either bandages or instruments. Such circumstances have several times occurred in our practice during the treatment of the extreme and complex sorts of club-foot, in children of from two to four years of age.'

The period of time required for the cure of club-foot varies a good deal according to the duration, and the particular form or variety of the deformity that exists. About four weeks may be considered to be about the average time required; but some cases do not require above three weeks, and others need nearly three months before a complete cure is obtained. Whenever the case is

of a complicated nature, as when the primary or essential deformity is associated with other deviations from the normal shape and direction of the foot, the treatment required will necessarily be not only more protracted and troublesome, but is seldom so perfect and complete as in simple cases.

Besides the cases of club-foot treated at the Clinique of M. Guerin, there were ten cases of wry-neck admitted. His remarks on this deformity are to the following purport:—

"You now know that the two phases-the ancient and the recent—of this deformity are two morbid states, very different from each other, of the muscular system, and which requires different methods of treatment. We have already explained to you that permanent contraction (contracture) is very different from retraction, and we have insisted the more on this distinction, seeing that no surgeon had attended to it before ourselves. The former is the spasmodic shortening of a muscle, without any appreciable alteration of its tissue, so that if the contracted muscle were stretched out, all its normal characters would be at once restored. The latter, on the contrary, is that shortening produced at first indeed by contraction, but in which the texture of the affected muscle has become subsequently more or less deeply altered, and has thus assumed a greater or less degree of fibrous or of a fatty consistence.

Attention to the distinction between these two very different conditions of a contracted muscle is necessary to the establishing of a scientific practice. If there be simple contraction, we may hope to effect an elongation of the contracted muscle by means of extension, rubbing, shampooing, &c.; whereas, if there be genuine retraction, the only rational method of relieving the deformity consists in dividing the affected muscle.

We have exemplified this distinction, before your eyes, in the treatment of wry-neck, according as the deformity has been of old or of recent formation; and the success which has attended our practice has abundantly proved the correctness of the diagnosis now pointed out.

Among the most useful means to promote the elongation of muscular contraction is the use of friction with antimonial ointment; the eruption which this excites has seemed to me to prepare the way for the more successful employment of extension. In three cases of wry-neck treated before you, the re-adjustment of the head has appeared to be intimately connected with the eruption of the pustules over the contracted muscle."

M. Guerin subsequently alludes to the operations of dividing the biceps,

semitendinosus, semimembranosus, rectus internus, Sartorius, &c. for relieving the deformities of the knee and hip. He concludes by stating that

"During the last four months I have performed before your eyes 68 operations of dividing tendons and muscles, in not one of which has any troublesome symptom supervened, and all of which (with upwards of 400 other cases of analogous operations performed by me during the last four years) tend to confirm the truth of my theory of subcutaneous wounds, and establish the superior advantages which I have attributed to this method of operating over the usual one."Gazette Medicale.

M. MALGAIGNE ON HERNIÆ.

M.

M. Malgaigne has, during the last season, delivered a series of lectures on herniæ at the central bureau of hospitals in Paris. From these we learn that, according to his statistical enquiries, nearly one-twentieth of the entire population in France are affected with ruptures. It is therefore one of the most important duties of every surgeon to make himself thoroughly master of every practical point on the subject of an infirmity that is of such frequent occurrence. Malgaigne very justly remarks that professional men have far too much neglected the management of reducible herniæ, and have left the construction of trusses altogether in the hands of mere machinists. He says, "A few years ago there was scarcely a surgeon, with the exception of Sir A. Cooper and some of his pupils, that knew how to put on a truss properly. The mere bandage-maker was certainly better qualified to advise a ruptured patient as to his truss than the medical attendant. Thus when Salmon proposed his apparatus, known in France by the name of the English bandage, our surgeons did not at all understand its simple mechanism, and they suggested some modifications which quite destroyed its utility."

M. Malgaigne confesses that he knew as little of the matter as any of his confreres, four years ago, when he was appointed examiner of all the herniary patients who presented themselves at the Central Bureau. From that period to the present he has examined upwards of 2000 cases of rupture and of prolapsus; and his attention has necessarily been directed in an especial manner to discover which are the most efficient and serviceable trusses. With this view he selected several cases in which the rupture was the least easily retained, and he shewed them to the various instrument-makers in Paris for the purpose of trying the comparative value of the different forms of trusses in the same patients and under the same circumstances-the only true way of determining their relative superiority. Some of these gentlemen acceded to the proposal with willingness, but others with an ill-dissembled reluctance.

According to the researches of M. Malgaigne, inguinal hernia is of much more frequent occurrence even in women-contrary to what is usually stated in books -than crural hernia.

The following observations on the prolapsus vaginæ are novel :

"It is usually stated by writers that vaginal cystocele is of exceedingly rare occurrence; whereas I find that it is the most common form of vaginal prolapsus. Again, rectocele was not even mentioned in surgical writings a few years ago; and yet it is quite as frequent as the genuine prolapsus of the uterus."

M. M. proceeds next to point out the relative frequency of hernia in the male and female sex.

Of 2767 cases, which he examined during the year 1836, 2203 occurred in males, and 564 in females; or about 4 to 1; and of 2373 cases examined in No. 81.

20

1837, 1884 occurred in the former, and 489 in the latter. The relative frequency therefore of hernia in the two sexes may be stated to be as 4 is to 1.

year

Relative frequency at different Periods of Life.

If we endeavour to discover the relative frequency of ruptures during the first of life to the entire number of cases taken at all ages from infancy to old age, we shall probably find that it may be stated at about 1-52 of the whole. It is not the same indeed in the two sexes; for it would seem to be about 1-38 in male infants, and only 1-62 in female ones. But even this proportion is much higher in the female sex than at all the other periods of life put together. The reason of this is easily given. During the first year of infancy ruptures are almost always either umbilical or inguinal. Now as to the former kind, the one sex is quite as much exposed to it as the other; and, even in respect to the latter, it is necessary to bear in mind that the canal of Meckel in female children is as frequently open as the inguinal canal in male ones. It is quite true however that the descent of the testicles must favour the predisposition to rupture at this point, and is to be regarded as the cause of the greater frequency in boys than in girls.

The frequency of ruptures diminishes very sensibly from the first to the second year; and this diminution becomes greater and greater till about the twelfth or thirteenth year. From about this period the tendency begins very sensibly to augment, at least in the male sex; owing no doubt partly to the incipient increase of development in the generative organs, and partly also to the violent muscular efforts which boys employ in their various sports. But it is chiefly from the 20th to the 28th year that the great increase of herniæ in both sexes is most emarkable. In women, exomphalos is not now unfrequent; and crural rupture-before this period of life excessively rare-is also met with. The changes that have taken place in the female pelvis and in its soft envelopes, more especially if the woman has married and become a mother, will at once account for the great increase of ruptures during the above-mentioned period of life. This increase amounts to at least a double; whereas, in the male sex, it does not exceed by one-fourth of what it had been.

From the 28th to the 35th year, the tendency to ruptures in both sexes seems to be stationary; but from the latter to the 40th year it again increases, and this very sensibly too.

From the 40th to the 50th year, it again decreases in men, but rather increases in women.

M. Malgaigne, from an examination of the tables drawn up by the medical officers of the army appointed to inspect the young men, between 20 and 21 years of age, who have to serve as recruits every year, estimates that at this period one in every 32 is affected with some form of hernia; that at 28 years of age there is one in every 21; at from 30 to 35 years, that there is one in every 17; and at from 35 to 40 years there is one in every nine. The ratio remains then stationary till about the 50th year; after that it rises to about a sixth; from the 60th to the 70th year to a fourth; and from the 70th to the 75th year to nearly a third of the male population.

With respect to the ratio of the number of persons affected with hernia to the entire population in France, M. Malgaigne states that he estimates it at a onetwentieth.

He next proceeds to examine the causes, predisposing and exciting, of ruptures. Among the former, hereditary tendency is one of the most influential. Of 316 cases of ruptures of different kinds he found that in 87 the parents of the persons had been similarly affected. Stature is another: a very large proportion of herniary patients being above the average height. This we might indeed, à priori, expect; as tall men are seldom so robust and strongly-knit together as shorter men.