gave the sensation of a deep-seated fluid. When grasped by the fingers in other parts, one might perceive an irregular hardness. This examination gave no pain.

It was moveable, but in a slight degree: not so much as a wen formed by an enlargement of the adipose membrane.

The cutaneous veins, which ran over its surface, were enlarged. Some idea of its growth may be obtained from the following particulars. It was first examined in July 1800, and it was then judged to be about half the size at which I found it. The patient had been lately at Harrowgate, and had used a hot bath there, which he apprehended had much increased the size of the tumour.

The integuments did not seem to be rendered thinner by the distention of the fungus, which I conceived to be lodged beneath and within them.'

A drawing of the disease, as it appeared on the arm, is added to illustrate this chapter.

In chapter V. on Dislocations, Mr. Hey has very judiciously recommended the gentle methods of reduction which were inculcated by the late Dr. Hunter.-A mode of extension, proposed by Mr. Lucas, is described: but, by some accident, the plate explanatory of it is wanting in the copy before us. We shall transcribe the short account of Mr. Hey's method of reduction, when the head of the os humeri lies behind the pectoral muscle:

'As the head of the bone lay at a considerable distance from the socket, I was apprehensive that the extension of the pectoral muscle might have caused a stricture upon the neck of the bone, and thereby prevented the head from returning into the axilla. I determined therefore to try what a gentle motion of the bone in various directions, accompanied with a slight extension, would effect.

While I was using this method, without the aid of any assistant, my colleague, Mr. Chorley, who was with me, put his hand upon the head of the bone, which he could feel through the pectoral muscle, and thrust it towards the cavity of the joint. Our motions happening to correspond, the head of the bone passed easily into the axilla, and was then reduced without difficulty, two assistants making the extension while I pressed upwards the head of the bone.'

In the formidable accident of a dislocation of the thigh-bone forwards and downwards, Mr. Hey directs the following me. thod of treatment:

In this species of dislocation, as the head of the bone is situated. lower than the acetabulum, it is evident, that an extension made in a right line with the trunk of the body, must remove the head of the bone farther from its proper place, and thereby prevent instead of assisting reduction. The extension ought to be made with the thigh at a right angle, or inclined somewhat less than a right angle, to the trunk of the body. When the extension has removed the head of the bone from the external obturator muscle, which covers

L 4

the

the great foramen of the os innominatum, the upper part of the os femoris must then be pushed or drawn outwards; which motion will be greatly assisted by moving the lower part of the os femoris, at the same moment, in a contrary direction, and by a rotatory motion of the bone upon its own axis, turning the head of the bone towards the acetabulum.'

This plan is elucidated by two cases.

In the sixth chapter, we meet with some curious and useful observations on Internal Derangement of the Knee Joint. The author's account of the symptoms of this complaint is as fol lows:

This disorder may happen either with, or without, contusion. In the latter case it is readily distinguished. In the former, the symptoms are equivocal, till the effects of the contusion are removed, When no contusion has happened, or the effects of it are removed, the joint, with respect to its shape, appears to be uninjured. If there is any difference from its usual appearance, it is, that the ligament of the patella appears rather more relaxed than in the sound limb. The leg is readily bent or extended by the hands of the surgeon, and without pain to the patient: at most, the degree of uneasiness caused by this flexion and extension is trifling. But the patient himself cannot freely bend, nor perfectly extend the limb in walking; but is compelled to walk with an invariable and small degree of flexion. Though the patient is obliged to keep the leg thus stiff in walking; yet in sitting down the affected joint will move like the other.

The complaint which I have described may be brought on, I apprehend, by any such alteration in the state of the joint as will prevent the condyles of the os femoris from moving truly in the hollow formed by the semilunar cartilages and articular depres sions of the tibia. An unequal tension of the lateral, or cross ligaments of the joint, or some slight derangement of the semilunar car, tilages, may probably be sufficient to bring on the complaint. When the disorder is the effect of contusion, it is most likely that the lateral ligament on one side of the joint may be rendered somewhat more rigid than usual, and hereby prevent that equable motion of the condyles of the os femoris, which is necessary for walking with firmness."

To understand the method of cure, it will be necessary to extract the second case of this disorder:

In 1784, the honourable Miss Harriet Ingram (now Mis. Aston), as she was playing with a child, and making a considerable exertion, in stretching herself forwards, and stooping to take hold of the child, while she rested upon one leg, brought on an immediate lameness in the knee joint of that leg on which she stood. The disorder was considered as a simple sprain; and a plaster was applied round the joint. As the lameness did not diminish in the course of five or six days, I was desired to visit her,

Upon

Upon comparing the knees, I could perceive no difference, except that, when the limbs were placed in a state of complete extension, the ligament of the patella of the injured joint seemed to be rather more relaxed than in that joint which had received no injury. When I moved the affected knee by a gentle flexion and extension, my patient complained of no pain; yet she could not perfectly extend the leg in walking, nor bend it in raising the foot from the floor; but moved as if the joint had been stiff, limping very much and walking with pain

I thought it probable, that the sudden exertion might in some degree have altered the situation of the cross ligaments, or otherwise have displaced the condyles of the os femoris with respect to the semilunar cartilages; so that the condyles might meet with some resistance when the flexor or extensor muscles were put into action, and thereby the free motion of the joint might be hindered, when the incumbent weight of the body pressed the thigh bone closely against the tibia; though this derangement was not so great as to prevent the joint, when relaxed, from being moved with ease.

To remedy this derangement, I placed my patient upon an elevated seat, which had nothing underneath it that could prevent the leg from being pushed backward towards the posterior part of the thigh. I then extended the joint by the assistance of one hand placed just above the knee, while with the other hand I grasped the leg. During the continuance of the extension, I suddenly moved the leg backwards, that it might make as acute an angle with the thigh as possible. This operation I repeated once, and then desired the young lady to try how she could walk. Whatever may be thought of my theory, my practice proved successful; for she was immediately able to walk without lameness, and on the third day after this reduction she danced at a private ball without inconvenience, or receiving any injury from the exercise.'

The next case relates a recurrence of the accident to the same lady, and its cure by the same means. This fact, with others of a like nature mentioned by Mr. Hey, seems to explain the success of some bone-setters, who acquire a reputa tion in practices of this kind, which they employ without any directing principle.

Chapter VII. relates to loose Cartilaginous Substances in the Joints. Mr. Hey's plan, in this troublesome and often dangerous complaint, consists in the use of quilted knee-pieces.

Chapter IX. treats of the compound Luxation of the Anclejoint; and we learn that Mr. Hey follows Mr. Gooch's plan of sawing off the head of the protruded bone.

We find many useful and important remarks, in chapter 10th, on Retention of Urine. The following are the author's general observations on this subject:

As this complaint may subsist, when the flow of urine from the bladder is by no means totally suppressed, great caution is required to avoid mistakes on this subject.

• Violent

• Violent efforts to make water are often excited at intervals, and during these strainings small quantities of urine are expelled. Under these circumstances, the disorder may be mistaken for the strangury.

At other times, a morbid retention of urine subsists, when the patient can make water with a stream, and discharge a quantity equal to that which is commonly discharged by a person in health. Under this circumstance, I have known the pain in the hypogastrium, and distension of the bladder, continue, till the patient was relieved by the catheter.

And lastly, it sometimes happens, that when the bladder has suffered its utmost distension, the urine runs off by the urethra, as fast as it is brought into the bladder by the ureters. I have repeatedly known this circumstance cause a serious misapprehension of the true nature of the disease.

In every case of retention of urine which I have seen, the disease might be ascertained by an examination of the hypogastrium, taken in connection with the other symptoms. The distended bladder forms there a hard and circumscribed tumour, giving pain to the patient when pressed with the hand. Some obscurity may arise upon the examination of a very corpulent person; but in all doubtful cases the catheter should be introduced.'

Mr. H.'s directions for the introduction of the catheter are valuable, but too long to be inserted. He prefers, in general, the removal of the catheter after each operation. Several cases are added, which tend to prove a very important fact, that dis. tension of the bladder may subsist, even when there is apparently a natural flow of urine; which the reader will under, stand from the ensuing cases:

In the early part of my practice, about forty years ago, I was attending Mr. Hepworth, an elderly man, who laboured under a retention of urine. I had drawn off his water morning and evening for a few days; when I was informed, that he had regained the power of relieving himself. About a pint of urine was shewn to me, as the quantity which he had made in the course of the night with a natural stream. I began to apprehend that my attendance would be no longer necessary; but as he still complained of the same uneasiness in the hypogastrium, I examined the state of the abdomen, and was surprized to find the bladder distended as much as it had usually been before his urine was extracted, and the operation was found to be as necessary as it had been before.

This case taught me the necessity of continuing to introduce the catheter, till it clearly appears, that the patient can empty his bladder by the natural efforts.'.

About two years ago I was desired to visit a patient early in the morning, whom I had repeatedly attended on account of a retention of urine. He complained of considerable pain in the hypogastrium, though he had made two quarts of urine in the course of the night. I found his bladder distended, and drew off about a pint of urine, which he had not been able to expel.

• When

• When there has been a necessity for extracting the urine by the catheter during two or three weeks, the power of expelling it voluntarily generally returns by degrees. The propriety of omitting the operation is not to be determined by the quantity of urine which the patient expels, but by the power of emptying the bladder.

Another source of deception is the involuntary discharge of urine, which sometimes succeeds a retention that is not relieved by the catheter. This is not so frequent an occurrence as the former; but it is highly dangerous, when the proper means of relief are neglected.'

An early introduction of the catheter is recommended in cases of retention.

For the cure of the Procidentia Ani, in adults, Mr. Hey advises the removal of the soft tubercles which commonly surround the anus in this complaint. By the inflammation which the operation excites, a firmer adhesion of the rectum to the surrounding cellular membrane is procured, and the tendency to prolapsus is thus obviated.

A case of convulsions, after temporary strangulation, is given to shew the impropriety of large and indiscriminate bleeding, while the powers of life remain almost suspended, after such an accident.

In describing a case which required the operation of Empyema, Mr. Hey observes that one half of the body was cede

matous.

We omit several shorter notices of different diseases, which, however, ought not to be overlooked by the medical reader; and hasten to the author's remarks on Amputation.

The succeeding extract will give a general idea of the method which he proposes:

When a flap is not made, which is usually unnecessary when amputation is performed in the thigh or arm, nothing more is necessary than to amputate with a triple incision, and to preserve such a quantity of muscular flesh and integuments, as are proportionate to the diameter of the limb. By a triple incision I mean, first, an in◄ cision through the integuments alone; secondly, an incision through all the muscles made somewhat higher than that through the integuments; and thirdly, another incision through that part of the muscular flesh which adheres to the bone, made round that part of the bone where the saw is to be applied. When these incisions are made in their proper places, the integuments and muscles on the opposite sides of the stump will meet each other conveniently, and may be preserved in contact so as to produce a speedy healing of the wound, and a convenient covering for the extremity of the bone.

The proper distances of these incisions from each other must be determined by the thickness of the limb, upon which the operation is to be performed, making allowance for the retraction of the integu. ments, and of those muscles which are not attached to the bone."

• I will