3. Fracture of the Patella.* We were rather surprized to find Mr. Fielding remark that, transverse fractures of the patella are of rare occurrence, when compared with longitudinal fractures. We believe that, in all cases where the fracture occurs from the action of muscles, it will be found to be transverse, while in accidents ab externo, it may be transverse or longitudinal according to circumstances. Be this as it may, our author advocates the practice of effecting an osseous union, if possible. Dupuytren advocated the same practice some years ago, and thought it possible to effect the bony union by elevating the trunk of the body, and then raising the heel of the injured limb to a certain angle with the pelvis. Mr. Wilson, also, in his late work, observes that, in the collection of Dr. W. Hunter, there was one well-marked instance of bony union in transverse fracture of the patella, and that he has seen other instances in the dead body of its having occurred. Professor Sheldon has recommended the patient to be placed on either side, with the hip bent, and the knee a little bent also the degree of inflexion of the hip to be equal to the bringing down the superior portion of the patella to unite with the inferior -a mode of practice which, he says, has produced a perfect bony union of the fractured patella. As the case on which this little pamphlet is founded, will occupy but a small space in our pages, we shall give it in the author's own words.

Case. "Mrs. H. æt. 35, a tall well proportioned woman, on the 13th Nov. 1820, lifting a heavy basket while in the erect positionher left knee suddenly gave way and she fell to the ground. Upon visiting her immediately afterwards, it was evident that the left Patella was fractured transversely near its middle. The ends of the fractured bone were above an inch asunder. She was put to bed upon a hair mattress--the trunk and shoulders were well elevated. When the affected limb was placed horizontally, the ends of the fractured Patella remained about the same distance from each other as before. The heel was now gradually elevated by my son, who was my assistant at the time, until the fractured portions were brought into close apposition. In this situation they were secured by straps of adhesive plaster put three parts round the limb, above and below the Patella, by bandage passed moderately tight above and below the knee in the ordinary way. A splint about twelve inches long was placed under the ham and slightly secured by bandage. The elevated position of the heel was strictly preserved-the whole limb was thus placed upon an inclined plane from the heel to the hip-the heel being the highest. The Patella being left nearly uncovered, it was easy now to feel that the fractured bone was in exact contact. The knee was kept moist by a cold lotion. No great pain and very

Case of Transverse Fracture of the Patella, &c. By Mr. George Fielding. Octavo, sewed, 1822.

↑ We tried the position recommended by Professor Sheldon, but did not succeed in bringing the fractured bone into contact by that plan.

little swelling ensued. The chief inconvenience which the patient experienced was from the stretching of the flexor muscles, she was however perfectly manageable and preserved her position with the utmost care, from an apprehension that eventual lameness might ensue from the injury, if by any unguarded motion the fractured bone should be displaced, and the cure rendered imperfect.

"At the end of a fortnight the bandages were replaced. It was then clear, that the fractured ends of the bone were in contact, from the tumefaction upon the Patella, and from the exact situation of the fracture being no longer distinguishable.

"On removing the bandages at the end of a month, the bone was found to be firmly united, without any intervening ligament whatever.-Only a small hard line a little elevated was discoverable in the course of the fracture. The heel was now brought down to a horizontal position-the shoulders were lowered-the splint and a ban. dage loosely applied were kept on at the request of the patient a week longer and gentle passive motion employed every day:-This woman left her room before the end of the sixth week. Diligent friction and frequent passive motion of the joint were necessary for some time. The flexibility of the joint and the power of the limb were gradually restored, and the patient now enjoys the use of the limb in every respect as perfectly as before the accident." 12.

We think Mr. Fielding's pamphlet would have been better as an article in some periodical journal, than as a separate publication. But, as the main facts, and the case itself, will now receive a wide enough circulation, Mr. Fielding's object will be completely attained.

4. Dislocated Thigh Bone. Mr. Cornish of Falmouth, has related a case of this kind, which may induce hopes of reduction at a later period than is usually supposed within the reach of cure. The patient was a seaman, first treated at St. Thomas's Hospital for fracture of the neck of the thigh bone, and discharged with the assurance that the limb would be useless for life. He was afterwards admitted into Guy's Hospital, when Sir Astley Cooper pronounced it dislocation, and tried all means of reduction without effect. He was therefore dismissed as an incurable cripple. About twelve months after the accident, viz. in 1813, he presented himself before Mr. Cornish, at the Falmouth Dispensary, on crutches, and gave the foregoing

account.

"On examining him," says Mr. Cornish, "I found the injured limb about two inches and a half shorter than the other, entirely useless, producing great pain on putting it to the ground, and the knee and foot turned inwards. There was considerable distortion about the joint, and the head of the bone appeared to have formed a socket

* Med. Repository, March, 1822.

1822]

Traumatic Tetanus.

181

for itself on the dorsum ilii. In short, he had every diagnostic symptom of the dislocation upwards, which Sir A. Cooper has so accurately marked in his valuable essay on this subject. In conse quence of the duration of the accident, and the failure of the attempts at reduction under the skilful management of Sir A. Cooper, his case was considered irremediable, and nothing was done for him. In March, 1818, I met the man walking without the least degree of lameness, carrying a heavy basket on each arm. On satisfying myself that he was the patient I had examined at the Dispensary, and on inquiring into the cause of his cure, he informed me, that, in the summer of 1817, five years after the accident, whilst on a passage from Falmouth to Plymouth in a little coasting vessel, the ship made a lurch, which knocked him down. At the moment he fell, he heard a loud crack in his hip; and, from that time, he put aside his crutches, and perfectly recovered the use of his limb. The man is now doing duty as an able seamen on board a ship which trades from this port to London." 201.

Mr. Cornish saw Sir Astley Cooper reduce a dislocation of the hip-joint of six months standing, which he heard Sir A. say was the most protracted case in which he had had success.

5. Traumatic Tetanus cured.* Messrs. Mercier and Parant, of Quebec, have recently encountered a case of this kind, in a man, 50 years of age, who, some days after being wounded in the foot by a large nail, became affected with opisthotonos. Our authors bled ad deliquium, and exhibited strong mercurial and other purgatives. The venesection was several times repeated, and the warm bath was employed. The patient recovered. It may be proper to state that the wound was re-opened by our authors when called in, and that burning spirits were applied to it to keep it open afterwards. Great difficulty was experienced in producing purgation.

6. Nervous Paralysis. We are very far from agreeing with M. Fouquier in the propriety of the name given to the disease in question, and our reasons will be seen as we proceed in the details of the case, which is an important one.

"A young woman, 19 years of age, very stout, of full sanguineous habit, with regular but scanty menstruation, experienced, on the 27th November, a loss of strength in the lower extremities, shortly after which the upper limbs also lost their power of voluntary motion. At the same time she felt vertigo, and noise in her ears; the

Med. and Phys Journal, Dec. 1821.

↑ Paralysie Nerveuse. Par M. Fouquier.-Annuaire Med. Chir.

intellect, however, remaining unaffected. Leeches were applied to the anus and to the neck. On the 1st December she entered La Charité; and on the 2d, presented the following phenomena :-total loss of voluntary motion in the lower extremities, and partial loss in the upper-sensibility unaffected in either. The patient was perfectly collected, and rendered an exact account of herself. She complained of dimness of vision, and tinnitus aurium. Her countenance was flushed, and a little tumid-the pupils dilated-the left angle of the mouth drawn a little backwards and upwards—the right in a contrary direction-her tongue inclined to the left when put out. The pulse was full and strong, but not quickened in number. All the signs of plethora being united in this girl, M. Fouquier ordered the jugular vein to be opened, but the quantity of blood drawn is not specified. Lemonade and cream of tartar for drink. 3d. Dec. Countenance still flushed-the distortion about the mouth less strik ing-considerably more power in the upper extremities-the lower remained motionless-tinnitus aurium. Another bleeding from the but the quantity and effect on the system not stated. 4th. Less power in the arms than yesterday-breathing difficult-pulse accelerated. Some evacuations provoked by an emetico-cathartic draught—a blister to the nucha-patient died in the evening.

arm;

"Dissection. The exterior vessels of the brain, and those of the plexus choroides, were full of blood-and blood appeared in numerous points of the brain at each cut of the scalpel. The substance of the brain itself was firm. No extravasation in the ventricles or in any part of the head or spinal canal.”

376.

In the first number of this series, page 10, we made some observations on this case, and shewed that there were unequivocal marks of general compression of the brain, which often led to the most fatal species of apoplexy and paralysis, without any extravasation of blood beyond the parietes of the vessels. To M. Fouquier's question then-"La plenitude des vaisseaux sanguins du cerveau est-elle la seule cause de cette paralysie générale et de la mort?" We answer yes; and we consider it by far the best and the safest conclusion to draw, whether we look to pathology or practice. The inert treatment in this case is a pretty significant commentary on the doctrine of "nervous apoplexy and paralysis," so commonly in the mouths of continental physicians.

7. Puncturing Anasarcous Limbs. We confess that we were not a little amused by this elaborate effusion of "a member of the Royal College of Surgeons," who, with some naiveté, believes that the measure here recommended will "prove itself to be of far greater utility in evacuating the fluid diffused through the cellular tissue of the body, than any eulogium he can bestow in favour of its restora

* Med. and Phys. Journal, No. 279.

in

66

tion." If indeed it have not infinitely more effect than a eulogium removing dropsical fluids, we fear its restoration is hopeless! The facts detailed in support of the measure are in the form of a supposition. Suppose I were called to A. B, &c" we shall not therefore analyse this supposed case of "anasarca of the lower half of the body, in consequence of palpitation of the heart," because we believe that no such case ever existed. There is a passage at page 363, which augurs but little of the great success attending this puncturing of anasarcous legs. "It has often," says he, "struck me with utter surprise at finding patients dead a few days after this operation. was resorted to-patients who had not the appearance of so immediately dying, at the time it was performed." This led our author "into many endless difficulties," which, however, in the next line proved not to be endless, for, like a ship coming to an anchor, he dexterously "extricated himself by bringing up to the following conclusions." These conclusions were, that the said sudden deaths "were attributable to the removal of the accumulation of the lymph, which, in the relaxed state of the system at this time, supported the circulation by means of its pressure, &c." For our own parts we would humbly hint that this honest gentleman need not accuse himself of the death of these patients for not having applied a bandage after the scarifications. The causes that produced the cedema of the lower extremities were far more likely to induce sudden death than the scarifications. After puncturing and bandaging, he knows of no medicine better to make a trial of "than fl. 3j. of the tincture of digitalis, in fl. 3iij. of the spiritus ætheris nitrici." If our author means this for one dose, there is rather too much of the digitalis. If he means the usual dose of digitalis to be given from the above mixture, then the quantity of spir. ætheris nitrici in each dose will avail nothing. We are sorry to see papers of the above description so carelessly sent forth to the world. Such papers deserve gentle

censure.

8. Phthisis. Dr. Carson's ideas respecting the circulation of the blood, and the elasticity, or, as he terms it, resiliency of the lungs, as an agent in that mysterious process, have long been before the public. He has lately proposed the application of his theory to practice. Considering, and doubtless with justice, that the lungs are at all times in a forced state of dilatation, (we mean while capable of respiration,) he attributes to this circumstance the difficulty of healing any lesion in them. And as experiments on animals, and accidents in man, have proved that air may be admitted into one side of the chest without much danger, Dr. Carson proposes that the operation be performed in cases of phthisis, in order that the lung of the side diseased may be rendered quiescent, and thus the abscess have time to heal.

• Essays, Physiological and Practical. By Dr. Carson, of Liverpool.