tions are gained, and his services will not often be thrown away. It is seldom, very seldom, we are inclined to think, that in young subjects the treatment, under the personal superintendence of a competent surgeon, will fail of success, if he does not himself fail in his efforts. Yet we cannot deny the truth of some remarks we once heard Mr. Skey make: "He knew of no disease that required more patience, more knowledge, more perseverance, more anxious watching day by day, before the end was accomplished, than joint disease." Mr. Johnson adds that, "in early life, the limb may generally be preserved." Mr. Hilton, in his Lectures' lately delivered at the College of Surgeons, told the assembled members of the College that they would be justified in believing something more than this as the result of treatment. Tamplin has said that, "out of the large number of cases of diseased joint in children, which had occurred at the Orthopedic Hospital, he had not seen one that failed to be cured by the most ordinary care and attention." Mr. It is wonderful how little inconvenience the patient sometimes suffers during the long period through which the disease is in progress. We have seen a lad with bony ankylosis of the hip-joint, the result of disease, which had been about two years in progress, without having had any professional treatment, and without rest, except for a few weeks of the time after a slight injury. During the greater part of the period he had been employed on a farm looking after cattle. A lad was lately referred to us by a professional friend, to whom he had that day applied on account of a pain in the shoulder. Three years before, he had received some sharp blows about the shoulder, under punishment from his schoolmaster. Pain and stiffness followed, which received but little attention from his parents, and none from anybody else. We found the head of the humerus firmly united by bony union to the scapula, without any sign of existing disease. On the subject of the painful startings, which so frequently harass the patient, and deprive him of sleep, when the position of the limb allows the action of the muscles of flexion and extension, where irregular pressure on the articular surfaces is maintained by the muscles in a state of spasmodic contraction, Mr. Johnson says, that "Dr. Bauer has proposed to divide the tendons of the contracting muscles, independent of any malposition, as a means of relieving the starting pains." This operation was proposed, for the same reason, about forty-five years ago, to the late Mr. Vincent, at St. Bartholomew's Hospital, by the house-surgeon of that day, now long retired from the practice of the profession, who with anxious but unavailing solicitude had watched the patients with ulceration of the cartilage in diseases of the knee-joint. Worn out with suffering, without other known means of relief, they gladly submitted to amputation. The division of the hamstring tendons could not, he said, put them in a worse position. Mr. Johnson gives some useful directions upon the subject of passive motion during the later stages of inflammation of the larger and more important joints, with the view of avoiding the stiffness or false ankylosis, which often follows severe inflammation or injuries. The importance of the position of the limb is pointed out. Mr. Johnson says, "the position assumed by the limb is practically of great importance, for it is capable of maintaining or aggravating the disease at the time, as well as of giving rise ultimately to great embarrassment in the event of ankylosis occurring." Where bony ankylosis becomes inevitable, he points out the urgent necessity for the surgeon's rectifying the position assumed by the limb; "for recovery by ankylosis to be desirable, the limb must be fixed in a proper position." Much discussion used to be held formerly upon questions of "proper position" in cases of ankylosis. Mr. Johnson has not entered much into these, beyond directing that the limb should be placed in the position in which it may be employed to the greatest advantage. In the elbow, it used to be said that the proper position was at about a right angle—at least, the test was that the patient should be able to put his hand to his mouth. Some years ago, a friend told us he had under his care a gentleman of education, a lawyer by profession, who had the misfortune to suffer from ankylosis of long standing in the left elbow-joint, the limit being extended much beyond a right angle. Pitying his helpless state,— unable to put his hand to his mouth, our friend inquired into the amount of disability which he suffered from the faulty position (as it was thought) of the limb. The patient, long practised in the use of the limb, gave his opinion that, if the joint was fixed, his own was at the proper angle. He enumerated, with the accustomed accuracy of his profession, the advantages he enjoyed (our friend begged him to put down the list in writing): he could do this, that, and the other— he could drive a coach and four-he could tie his neckcloth (he showed how he did it). Many other things were within the compass of his power; "and," added he with a smile, taking our friend by the collar, "I can give a fellow a good licking." Not long since, a lad passed under our observation with his right elbow ankylosed at an obtuse angle. When a boy, he was well able to clean knives and shoes he is now employed as teacher in a village school. Next after the essays upon the diseases follows one by Mr. Holmes, upon Excision of Bones and Joints. This comprises an inquiry into the indications for such an operation, as well as descriptions of the operations, and the parts, whether bones or joints, accessible to such treatment. The cases suitable for excision are pointed out, and the rules given for the operations for removal of bones, or for the excision of their articular extremities, and for the aftertreatment of the cases, are remarkably good; they show an abundant amount of practical knowledge of the subject, and an intimate acquaintance with every matter of detail. Mr. Holmes is not to be classed as one of the most strenuous advocates for the modern operation of excision of joints. He has examined the subject carefully, and without any undue bias in his own mind, often calling in question the statistics which have been publicly brought forward to support the propriety of the operation, and the frequent necessity for it, as well as the comparative superiority of it over other kinds of operative interference. The conclusions deduced from a number of cases, even numerically successful, would be more satisfactory if, instead of instituting comparison between the results of two kinds of severe operations (amputation and excision), the comparison was made between the cases which are the subjects of these operations on the one hand, and, on the other hand, those which are treated by position and constitutional treatment. The cases in which this last system of treatment fails, are those only in which either of the two operations in question can be justifiable. "It may be laid down as a general rule," observes Mr. Holmes, "that a large or important joint ought not to be excised while any reasonable prospect exists of a cure without operation." How often is it that such a prospect fails, and what are the circumstances, when it fails, which encourage the hope of restoration to health, or usefulness of limb, from excision of a joint? These are questions, we submit, well deserving farther and more extended investigation than they have yet received. When the question of excision of the knee-joint was before the Medico-Chirurgical Society, between five and six years ago, Mr. Skey said, “it was a striking fact that these remarkable cases of excision came from comparatively few quarters, and were not spread over the whole of the profession: they were confined to a few persons, with whom the practice appeared to be the rule rather than the exception." It would seem that while one practitioner cures by "rest," another cures by excision, and a third finds a cure impossible, or perhaps only improbable and removes the disease altogether by amputation of a limb. Mr. Holmes's views, as he here puts them forth, that many cases may be cured, and that some, which he points out, must be submitted to excision, will lead the way to sounder and more justifiable conclusions. Mr. Shaw's contribution to the present volume consists of a single essay, upon the diseases of the Spine. This should be read in connexion with that upon injuries of the same region in the former volume. The essay in this volume is confined to disease of the bodies of the vertebræ-the "Pott's disease" of former writers-bringing under notice the symptoms of incipient disease, the diagnosis from neuralgia or hysteric affections, the deformity of real disease, as opposed to mere weakness of ligaments, the formation of abscess, and the treatment to be followed. Upon all of these, Mr. Shaw's essay is full and discriminating. Although not one of the order of "specialists," Mr. Shaw's acquaintance with all matters bearing on the diseases of this region is evidently extensive and practical, and his teaching is instructive. A short paper, by Dr. Brown-Séquard, upon the diseases of the Nerves, closes the series of diseases of the organs of locomotion and innervation. The writer describes the effects produced by irritation of the centripetal nerves, and the affections which may be caused by injury or by disease; and he gives some rules for diagnosis and treatment of diseases and injury of branches and trunks of nerves. Much, undoubtedly, of the physiology of the nervous system still remains unexplained. In the treatment of the diseases of the nervous system, it does not seem that our knowledge advances at the same rate as that of other parts of the system. Dr. Brown-Séquard remarks that "the rules for general treatment vary according to the kind of reflex affection to be treated." The last essay in the present volume is a short paper by Mr. Coote, upon diseases of the Tongue, being the first of the series of Essays on diseases of the organs of digestion, which are to form part of the forthcoming volume. This essay comprises much practical matter within a small space. The description of the diseases, many of which are highly important, though it cannot be said that they are very numerous, are clear; and the treatment to be followed, operative or otherwise, is pointed out. REVIEW III. 1. Die vorzeitigen Athembewegungen: ein Beitrag zur Lehre von den Einwirkungen des Geburtsactes auf die Frucht. Von Dr. HERMANN SCHWARTZ.-Leipzig, 1858. pp. 308. On Premature Respiratory Movements: a Contribution to the Theory of the Action of the Process of Birth upon the Fœtus. HERMANN SCHWARTZ. By Dr. 2. Ueber das Athmen der Kinder vor der Geburt in physiologischer, anatomischer, und forensischer Beziehung. Von Dr. MAX BÖHR (Henke's Zeitschrift für die Staatsarzneikunde,' 1863. Heft. pp. 1-107.) Erstes On the Respiration of Children before Birth in relation to Physiology, Anatomy, and Forensic Medicine. By Dr. MAX BÖнR. 3. Beiträge zur Lehre von der Todesart der Kinder während der Geburt, mit bezug auf die Theorie von der Placentar-respiration. Von Dr. C. HECKER. (Verhandlungen der Gesellschaft für geburtshülfe.')-Berlin, 1853. pp. 145-196. Contributions to the Theory of the Cause of Death of Infants during Birth, with reference to the Doctrine of Placental Respiration. By Dr. C. HECKER. 4. Lehrbuch der Geburtshülfe. Von Dr. A. F. HOHL-Leipzig, 1855. pp. 1139. Text-book of Midwifery. By Dr. A. F. HOHL, 5. Zur Lehre vom Vorfall und von der Umschlingung der Nabelschnur unter der Geburt. Von Dr. L. KRAHMER. (Deutsche Klinik,' 1852, p. 289, et seq.) On the Theory of the Effects produced by Prolapsus and by Loops of the Funis during Birth. By Dr. L. KRAHMER. THE theory that the placenta is, during embryonic life, a respiratory organ-that the foetal villi absorb not only nutritious matter, but also oxygen, from the maternal blood, by which they are bathed, has received among physiologists and obstetricians, in this country at any rate, a very general acceptance. But this agreement is by no means universal; there are some who, with Scanzoni and Kiwisch, refuse to admit the aëration of the foetal blood; and there have been others who, granting this fundamental point, have attributed to other parts than the placenta the functions which are exercised by the lungs during extra-uterine life. Among the text-books of physiology in ordinary use in England, we may mention that of Kirkes,' in which the respiratory function of the placenta is—at least, by implication-denied. Moreover, those who admit it generally refrain from giving any reasons for the views which they hold; and it must be conceded that those arguments upon the subject which are to be found in Müller's Physiology' and elsewhere, are not very conclusive, being chiefly of a presumptive character. Of late, however, attention has been drawn to certain effects of interruption of the placental circulation, which had previously been only partially observed; and the result of these investigations has been to lend powerful aid to the theory that the placenta is the seat of an interchange of gases, essentially equivalent to respiration. It had long been known that, under certain circumstances, respiratory efforts are made by the fœtuses of animals, even while enclosed in the membranes, and that, as a result of these movements, liquor amnii and other fluids may find their way into the trachea and bronchi of the embryo; but now it is shown that such respiratory efforts are the immediate and necessary consequence of obstruction to the circulation in the placenta, and that when no fluid can enter the air-tubes, their occurrence may be recognised by another class of effects, of an equally characteristic kind. In this case blood is drawn into the pulmonary vessels; and if the obstruction continue, it exudes through the thin walls of the capillaries into the lung-tissue, forming ecchymoses, and the space created by the expansion of the thoracic parietes is in this way filled up. Now, if these facts be correct, it seems impossible to deny the respiratory function of the placenta. These movements can be related to the cause which is found to produce them only as the result of a "tésoin de respirer." This must be caused by the interruption of a process of aëration which had before been actively going on; and the conditions of the experiment are sufficient to show that this function was located in the placenta. But their physiological interest is not the only one which attaches to these observations. They have a wide bearing also in both obstetrical and medico-legal practice, and therefore we propose to bring before our readers the chief points which have been hitherto ascertained; and we have thought it desirable to preface our remarks by a brief résumé of the evidence in favour of the respiratory function of the placenta, which existed before these recent additions to it were made. It may be remarked, in the first place, that no clear idea of pla 1 Handbook of Physiology, fifth edition, p. 275. |