M. GUERIN ON SUBCUTANEOUS ORTHOPODY. We are informed by this indefatigable reformer of deformities that within the last four years he has performed upwards of a thousand operations for the section of muscles or tendons in different parts of the body. The following catalogue of muscles divided he gives in the number of the French Medical Gazette for last May. 1. In the neck-the sterno mastoideus, cleido mastoideus, trapezius, angularis scapulæ, splenius, complexus colli, and cervicalis descendens. 2. In the back-the trapezius (along its entire attachment to the scapula), rhomboidens (along its entire attachment to the scapula), dorsalis magnus, sacro-lumbaris, longissimus dorsi, and transversalis dorsi. 3. In the upper extremities-the deltoideus, biceps, supinator longus, radialis anticus, ulnaris anticus, flexor sublimis, and extensor digitorum communis. 4. In the lower extremities-The psoas and iliacus, (psoas-iliaque), adductorlongus, sartorius, rectus anticus, tensor vaginæ, glutei, biceps, semi-tendinosus, semi-membranosus, rectus internus, tendo-achillis, tibialis anticus, tibialis posticus, flexor communis longus et brevis, flexor pollicis longus et brevis, extensor longus communis, extensor pollicis, peronei anticus et laterales, plantaris, adductor and abductor digiti minimi. 5. Aponeuroses-fascia lata, and plantaris. 6. Ligaments-sterno-clavicular, scapulo-humeral, coxo-femoral, lateral of the knee, tibio-astragular, lateral and posterior astragulo scaphoid capsule, and scaphoid-cuneiform capsule. ON THE SUBCUTANEOUS INCISION OF JOINTS. In a former memoir on subcutaneous wounds-vide the last number of the Medico-Chirurgical Review-M. Guerin has shewn that, as long as wounds are kept quite excluded from the contact of the air, there is seldom any tendency to inflammation set up, while the healing of the divided parts is usually effected very rapidly. Hence the importance of performing certain operations without making more than a mere puncture of the integuments. In his second memoir the author proceeds to shew by experiments on men and on animals, that the subcutaneous incision of joints is as exempt from danger as that of tendons, muscles, nerves, and small blood-vessels, and moreover, that it may afford in certain cases a valuable means of cure in the hands of the scientific surgeon. In two dogs he opened successively, by the subcutaneous method, the humerocubital, the radio-carpal, the femoro-tibial, and the tibio-tarsal joints; and he found that, whenever the wounds were kept quite excluded from the admission of the air, they rapidly healed without any inflammation. When the joints thus opened were allowed to be moved about, a synovial swelling usually appeared around the wound, but when they were kept quite quiet and extended, even this trifling accident did not supervene. If however the air was permitted entrance, inflammation and subsequent suppuration were invariably induced. M. Guerin, reasoning upon the results of these experiments as well as upon what is well known to happen after some severe dislocations, very rightly inferred that there cannot be any essential danger in making an incision into a joint, provided the air be excluded from the synovial cavity. He has now in several cases divided the ligaments and portion of the capsules of the knee and ancle-joints; and in none of these operations has any unpleasant symptom manifested itself. The wound in the integuments should always be as small as possible, and far distant from that into the joint: moreover it should be made when the limb is extended, and never when it is bent; and lastly, the joint should be kept perfectly motionless for some days afterwards. "These two last-named injunctions, are," M. Guerin observes, "the more necessary to be attended to, as I have discovered recently that in all the movements of joints their cavities become more or less enlarged, and therefore that as a vacuum is thus formed, there is a strong tendency to the suction of air, if any communication exists with the outer surface." In the third part of his memoir, the author points out the useful applications which may be made of his researches to the improvement of surgery. Serous, sanguineous, or purulent collections within the joints may be evacuated without danger. Among the most extensive and important applications, he mentions the subcutaneous division of articular ligaments and capsules, with the view of maintaining in a fixed condition certain congenital and also some old dislocations after they have been once reduced; also the exciting of adhesions, and favouring the formation of new articular cavities. Already he has effected in this way the cure of a congenital luxation of the clavicle which had resisted every means that had been tried, by making numerous sections of the ligaments all around the displaced joint. ON CONGENITAL SUBLUXATIONS OF THE Femur. The following are the conclusions which M. Guerin has drawn from all his researches on this question. 1. Congenital luxation of the femur is, like club-foot, wry-neck, and deviations of the spine, the result of primary muscular retraction; and the various forms of this luxation considered as to their seat, their direction, and their degree, are produced by the muscular retraction being differently distributed, and by its elements being differently combined, in the muscles of the pelvis and of the thigh. 2. There is an order of congenital deformities of the hip, which has not been noticed by any writer, and which I have called pseudo-luxations, because they present the deceptive appearance of luxation without the escape of the head of the bone from its socket;-this also is the result of muscular retraction. 3. The essential treatment of these deformities, independently of the means already known, consists in the section of the retracted muscles. I have already performed this operation three times with success. These remarks are equally applicable to the congenital luxations of other joints. The essential cause of all, wherever they are seated, is what we have stated above-viz. primitive retraction of the muscles inducing shortening, partial paralysis, and arrested development of their tissue. A few weeks ago I divided the biceps, semitendinosus, semimembranosus, and rectus internus muscles in a case of incomplete luxation of both knees, which occurred in a girl fourteen years of age on each side there was a sub-luxation of the tibia backwards upon the condyles of the femur, a considerable rotation outwards of the leg, and also an inclination outwards of the leg upon the thigh of nearly 60 degrees. On the day after the operation the outward rotation, the lateral inclination, and this displacement backwards of the tibia were no longer perceptable, and there was merely a certain degree of flexion of the leg upon the thigh: the cure was complete, with the exception of this partial flexion remaining permanent. To give confidence, adds M. Guerin, to those who have not had an opportunity of witnessing the innocuous nature of subcutaneous operations, I may state that the other day, in the case of a young girl, I divided thirteen different muscles or tendons for the relief of various deformities, and that from the following day she experienced neither pain nor malaise, nor any symptom of inflammation in the seat of the divided muscles.-Histoire des Difformités du Systeme Osseux. OPERATIVE MIDWIFERY IN HOLLAND AND GERMANY. A woman, 26 years of age, and who had been twice before delivered of dead children by means of the forceps, became a third time pregnant. Dr. Gelauff, who had attended her in her former pregnancies, unwilling to expose himself to the recurrence of so much difficulty as he had met with before, and wishing moreover to deliver a living child, resolved to perform the operation of dividing the symphysis pubis for the purpose of increasing the antero-posterior diameter of the inlet of the pelvis-which he ascertained to be less than three inches. The operation was performed between five and six o'clock P. M. we are told, according to the rules of art; and the bones were separated a little less than half an inch. The pains did not come on briskly for several hours afterwards; but about ten o'clock they increased so much that, very soon afterwards, the child was expelled alive. The placenta also came away as after a natural labour. The recovery was altogether so satisfactory that the woman was able to walk about at the end of the fourth week. Cases of Cæsarian Operation. A woman, 32 years of age and seriously deformed from rickets, unfortunately became pregnant. At length the period of labour came on, and Dr. Straek of Cassel ascertained that the child was alive, but that the pelvis was so much contracted that no living child could pass through it. The operation of extracting the child by the Cæsarian section was therefore determined on. Having divided the abdominal parietes and peritoncum in the usual manner, an opening was made into the uterus and sufficiently enlarged to enable the operator to introduce his hand, turn and bring out the foetus-the placenta also was easily removed. The uterus immediately contracted upon itself, and expelled a quantity of coagula which were carefully wiped away. The contraction being deemed sufäcient-half an hour clapsed for this purpose-the external wound was brought together by several stitches, and long strips of adhesive plaster. The child, when put into a bath, cried lustily. The mother, in spite of two or three attacks of pulmonic irritation which required venæsection, ultimately recovered most satisfactorily. For the first few days she was able to suckle her child, but, the secretion failing, a wet-nurse was engaged. Dr. Hoebeke of Brussels, whose extraordinary success in Cæsarian operations we gave a short account of in the Number of the Medico-Chirurgical Review for October of last year, has apper ded to the above account the report of the following case which occurred in his practice so far back as the year 1829. We presume that it is the same gentleman, although in our preceding notice he is designated M. Hoebecke of Sottegem in Flanders. He has performed the operation thirteen times; ten mothers and nine children have been saved. The fatality of the operation in the practice of other medical men he attributes not No. LXVI. Мм Case 2.-A poor woman, who was miserably rachitic, had been in labour for three days when Dr. H. was called to her assistance. He found that the anteroposterior diameter of the pelvis measured less than two inches. Various fruitless attempts having been made by the accoucheur in attendance to apply the forceps, and extraction per vias naturales being in truth impracticable, the Cæsarian operation was at once resolved on. The child was found to be dead, when taken out. The woman was completely cured, we are told, by the end of the third week. (!) Remarks. We have repeatedly condemned the unjustifiable disregard of maternal life in various countries on the Continent, as exhibited in the readiness with which the medical men perform the frightful operation of the Cæsarian section. Not only in Germany and Holland, but even in France, where the surgeons and physicians, to their credit be it said, are usually among the foremost to adopt any acknowledged improvement in all the departments of the healing art, is this operation much more frequently resorted to than with us, but it is often undertaken under circumstances which every unprejudiced person, be he medical or not, will surely not hesitate to condemn. For example, the pelvis of a woman may not be so well formed as to give passage to a full grown nine months' child, but yet be sufficiently ample to permit a seven months' child to pass; and as it is well known that children at this premature period are usually viable or capable of sustaining life, then why allow any poor deformed creature to go her full period of gestation, with the inevitable prospect of a dreadful operation before her eyes? We have more than once within the last few years alluded to cases where women have actually been admitted into hospitals in the sixth and seventh months of pregnancy at which period the deformed state of their pelvis has been ascertained, and yet no step has even been thought of to avert the horrid catastrophe impending over them. Nay cases have been reported where women, who have actually undergone the operation once, have been received again, in a subsequent pregnancy, to be subjected to it a second time! Let us hope, however, that a more humane, aye too and a more scientific feeling will soon be manifested among our Continental brethren, and that they will be induced to imitate the example set by all the most eminent accoucheurs in Britain-we mean that of bringing on artificial labour at the seventh month or earlier, in cases of ascertained deformity of the pelvis. We perceive, by some of the late reports of the Academy of Medicine, that one of the leading obstetrical authorities in Paris, M. Dubois, has been acting on this principle in the case of a poor dwarf who had unfortunately become pregnant. Labour was induced at the beginning of the eighth month by means of a piece of sponge introduced into the os uteri, and of the administration of the ergot of rye,* both by the mouth and in enemata; the child was born alive, and the mother recovered most favourably. so much to the dangers necessarily consequent upon it, as to it having been undertaken at inopportune times. The particulars of his extraordinary success will be found in a volume which he has recently published and entitled Observations Pratiques de Chirurgie et d'Obstetricie. *We are surprised to find that so intelligent an accoucheur as M. Capuron should question the propriety of the practice of his colleague in this case. The only reason that he gives is, that he has known a case of a woman, whose height was short of three feet, giving birth to a living child at the full time. Surely it does not follow that, because she was so diminutive, her pelvis was not developed. As a matter of course, the size of the pelvis is to be ascertained before we resort to the induction of labour. In a recent number of Schmidt's Jahrbucher, we find a report of a successful case of Cæsarian operation performed by Dr. Michaelis of Kiel; and short notices of several other cases which have occurred in different countries within the last year or two. They are as follow : 1. Cæsarian operation fatal, by Mr. Ward, (extracted from an English journal). The inlet of the pelvis was not more than one inch in its antero-posterior diameter, in consequence of the extreme projection of the sacro-vertebral angle; the fœtus was dead. 2. Cæsarian operation; extraction of a living child; death of the mother on the third day. Another fatal case is also recorded by the same gentleman, Dr. Hamm; and both are detailed in a late number of the Neue Zeitschrift. 3. Cæsarian operation successfully performed for the second time on the same woman, by Dr. Foy.-American Med. Journal, 1838. 4. Successful case of the Cæsarian operation, by Dr. Bauer.-v. Journal de Siebold, t. xvi. 5. Successful case by Dr. Hertzbruch; death of the child.-v. Neue Zeitschrift. 6. Successful case by Dr. Wiefel.—v. Casper's Wochenschrift. 7. Second history of a successful Cæsarian operation by Dr. Schenk.—v. Siebold's Journal. 8. Successful case by Dr. Petrenz.—Ibid. To these cases we may add another in which M. Dubois performed the operation last March, at the Clinique des Accouchements in Paris; the child lived, but the mother died on the sixteenth day after the operation of tetanus, after the fairest promises of recovery. In the report of this case it is stated that M. Dubois has now performed the operation five times every one of the patients has died. Contrasted with this, the success of the German and Dutch practitioners is indeed surprising. We read of the operation having been performed two, three, and even four times on the same woman! It seems almost incredible that any woman would expose herself to such inevitable suffering after having once undergone this most frightful operation; and yet from a report of M. Michaelis it appears that of 40 women who had recovered from it, 15 of them again became pregnant! ON THE SWEATING REGIMEN OF DR. PRIESSNITZ AT GRAEFENBERG. For some years past a Dr. Priessnitz has acquired a great reputation over Germany for the success which has attended his practice for the cure of chronic diseases, and which has made his residence at Graefenberg visited by invalids from all parts of the Continent. Dr. Bigel, Knight of the Legion of Honour, and one of the Medical Professors in the Imperial College at Petersburgh, has recently published an account of this regimen, under the title, "Manuel d' Hydrosudotherapie, ou Traitement des Maladies par l'eau froide, la sueur, l'exercice, et le regime." He seems to be an ardent admirer of the sweating regimen as pursued at Graefenberg, and, as he has derived personal benefit himself from its adoption, we may attach the more credit to his statements. Dr. Priessnitz is evidently a disciple of the old humoral school of pathology-and we believe that in this respect he is far from being alone either among his own countrymen, or his professional brethren in England and France-for he considers almost all diseases to arise from the existence of some morbid or peccant humors generated This gentleman has performed the operation in three other instances; and in two of these it was successful. M м 2 |