SECTION OF THE FLEXOR TENDONS OF THE KNEE IN WHITE
SWELLING.

One of the most successful applications of Tenotomy is unquestionably that of dividing the flexor tendons in certain cases of diseased joints, with the view of insuring the perfect quietude of the articular surfaces. It has been tried by several surgeons in White-Swelling of the Knee, and, we rejoice to say, with very promising success.

M. Ribes, a man of great experience, has recorded his opinion of the practice in the following words:

"The medical art is rich in therapeutic remedies for the relief of Whiteswelling of the Knee-joint; but, in almost all cases, a simple cause has made them to prove utterly inefficient. This cause is the forced and permanent contraction of the flexor muscles of the leg. Eh bien! Why should we not perform, at the proper time, the subcutaneous section of the tendons of the Semi-membranosus, Semi-tendinosus and Biceps muscles, which keep up this uneasy state of things? By this easy operation, we may rationally hope not only to relieve the existing pain and distress, but also very materially to promote the formation of anchylosis, and consequently the cure of the disease. This simple and safe operation is already admitted and recognised by surgeons."

M. Ribes is one of those men whose name alone is worth a multitude of authorities, and whose simple approval will often weigh more than the most elaborate commendation of others.

M. ROGNETTA ON THE DYNAMIC TREATMENT OF CANCER.

Let us first enquire what is meant by the phrase of Cancerous Diathesis, and what is the nature of the dynamic condition that accompanies it. We have the choice of two doctrines or theories on the subject.

According to one of these, the existence of the diathesis in question precedes, in an occult manner, the formation of the local cancerous tumor; whereas, according to the other, it is the consequence and result of the absorption into the general system of the poisonous matter from that morbid growth. The late Baron Boyer maintained the first of these opinions, and insisted upon its adoption with great earnestness; but most of our leading metropolitan surgeons in the present day-Roux, Velpeau, Gerdy, Lisfranc and Blandin-reject the doctrine of primitive diathesis, and therefore regard the disease of Cancer as strictly local in its nature at first. The partisans on both sides appeal to the results of operations; but, alas! the conclusions, to which they arrive, are very different. The one party maintains that there is very generally a relapse after the diseased growth has been extirpated; while the other contends that such is not the case, if the operation be performed sufficiently early.

M. Rognetta seems to adopt an intermediate opinion; for we find him saying that, "it is perhaps more reasonable to admit that the local disease and the constitutional diathesis are developed simultaneously and proceed pari passu, and that the latter continues and advances after the tumor has been removed, just as much as when it is allowed to remain. There are even some reasons for believing that the re-action, which inevitably follows upon any severe surgical operation, must tend to accelerate the progress of the constitutional affection, if this be not counteracted by the administration of appropriate dynamic remedies. This perhaps is the reason why some practitioners of large experience have ultimately come to the conclusion of dissuading in all cases the removal of a truly cancerous tumor,

in place of trying to find out any therapeutic means to arrest the advance of the morbid diathesis."

M. Rognetta's pathological views are partially expounded in the following passage they appear to us to be in some points very fanciful.

"We do not say, with the Physiological School, that Cancerous disease is the product of Inflammatory action; but we are quite prepared to assert that the dynamic condition of this affection is in all its stages of a decidedly hypersthenic character, and also that it exhibits many points of resemblance with Chlorosis and Scrofula, more especially with the first of these morbid conditions. This assertion may seem strange; but we shall now endeavour to establish its probability.

"During the development of a cancerous growth, the system very generally will be found to exhibit symptoms of hypersthenic excitement; and, although the health may seem good, there is almost always a predisposition to inflammatory and congestive diseases. Be it remembered that a hypersthenic state of the body may exist without any actual excess in the quantity of the circulating fluid; and moreover, that this state, when it affects a great system,-the vascular tree, for example, as in Cancerous and Chlorotic patients cannot be effectually got rid of under the mere influence of bleedings, whose action is but transient and of short duration. We must therefore have recourse to certain dynamic remedies, which exert an elective operation on the system that is chiefly implicated; and, when we have found such, we must persevere in their use for a very considerable length of time. We know that some eminent pathologists see nothing in Cancer and Chlorosis except mere affections of the blood: but this is certainly a great error. They mistake the consecutive effect for the primary disease, and, by following a false path of enquiry, they inevitably land in recommending a faulty practice.'

As to the therapeutic part of the question, M. Rognetta seems to dwell chiefly on the high importance of diminishing and, if possible, subduing the hypersthenic condition of the vascular system, whether an operation for the removal of the cancerous tumor may be deemed expedient or not. It is from having neglected to attend to this constitutional affection before, as well as after, the performance of any surgical operation, that the disease is so often observed to return, even when every portion of the morbid texture has seemingly been utterly removed.

Our author carries his peculiar views so far that he even sees in the pallid hue of the skin, when the disease has reached its second stage, that of softening and ulceration, evidences of the hypersthenic excitement of the capillaries of the skin-the circulation in these vessels becoming gradually more and more completely extinguished, and consequently the process of assimilation, which depends upon their healthy condition, being quite interrupted.

66

Examine," says he, "the large vessels, and you will find them hard, thick and resistent, as in all genuine hypersthenic affections; and moreover do we not always observe that everything, which excites the vascular system-as, for example, the use of a stimulating diet and spirituous liquore-very strikingly aggravates the state of such patients, and always increases their pallor and weakness?

"The icteric discolouration of the surface, in the more advanced stages of the disease, is the effect of the extreme decay of the organic functions and the consecutive impoverishment of the blood, and finally of the resorption of the cancerous matter into the system."

*

M. Rognetta gives sound advice when he insists upon a certain course of constitutional treatment to be adopted both for some time before, and for a length

་

of time after, an operation has been performed. Whether he is right in his opinion that such treatment should invariably be directed to the correction of hypersthenic excitement-or, as our author expresses it, 'l'espece d'incendie devorant'-may, we think, be fairly disputed; but an objection on this score does not necessarily invalidate the general expediency of his therapeutic suggestions.

Among the Hyposthenic remedies that are most serviceable alike in Cancerous and in Chlorotic affections, he enumerates repeated small bleedings, also steel, quinine, hemlock, the aerated alkaline waters, acidulated drinks, warm baths, a mild unirritating diet, and the avoidance of all physical and moral excitement. These remedies have never cured Cancer, it will be at once replied. True, but then it may be fairly asked in reply, have they ever been used with sufficient perseverance and discretion? Medical men have always been looking out for specifics; and they have rarely followed out any plan of constitutional treatment upon rational principles, for a sufficient length of time. When the disease has made considerable advances, the remedies which we have mentioned, although useful, cannot be expected to effect any very decided benefit; unless, indeed, they be so judiciously combined together, as to maintain the vascular system in an unvarying state of hyposthenia. Then we must also have recourse to the exhibition of more energetic means; as, for example, the preparations of Iodine, Arsenic, Mercury, &c.-which may be often very advantageously combined with the remedies of which we have already spoken.

We may here state, as a general rule, that these active poisonous drugs will always act more surely and decidedly, if administered in minute doses, and dissolved in a large quantity of fluid, so as to form a sort of mineral water. Thus given, they are much more readily absorbed into the system, and moreover, their irritative local action on the stomach and bowels is at the same time avoided.

The following practical remarks by M. Tanchon, who has paid so much attention to the pathology of Cancer, are well deserving of general notice.

"Mercury, Iodine, and Arsenic are the three remedies which I have most extensively used. Of these, Mercury is certainly the most potent sedative (le plus hyposthenisant) of the white or lymphatic vascular system that I know. By its aid, I have often taken the colour from the most sanguineous habits in the course of a few days. One of the best forms for using it is the Unguentum Neopolitanum or Pommade di Vigo, applied externally. Sometimes, however, the tolerance even of this simple form, on the part of the system, is by no means great; for I have seen it several times bring back engorgements which had already disappeared, and even produce pain, which it so generally soothes in a very remarkable manner.

Iodine is an excellent remedy, when the stomach will bear its administration. The tincture is not a good form for giving it: an aqueous solution is greatly to be preferred. I occasionally use it as an outward application, combining small doses of Iodine in powder with starch, and then mixing this with Camphor or Belladonna, according to the indications of the case: this is what I call my pulvero-topique. The ioduret of Arsenic is the form in which I prefer to administer the latter active remedy. It should be given in very minute doses, and these very largely diluted. When the system bears, as it sometimes does, enormous doses of Arsenic without suffering, we may fairly presume either that the cancerous disease is incurable, or that the action of the remedy is directed on some other point of the economy."

So much for M. Tanchon's experience. According to M. Rognetta's observation, the Ioduret of Potassium is essentially a sedative of the vascular system. He condemns the use of Opium in all its forms; it acts, says he, almost always as a stimulant, and therefore cannot fail to prove injurious in Cancerous diseases.

Conium and Belladonna are not liable to the same objection. The former of these narcotics was certainly at one time vaunted too highly; nevertheless it is an excellent remedy, and should be used at a much earlier period of the disease than is usually done. M. Rognetta objects to the form of pill in which it is so generally exhibited; it would be decidedly more efficacious, if it were given in a fluid state, by being dissolved in a large quantity of water. In many cases it may be very serviceably associated with quinine, steel, and sometimes also with sulphur.

With respect to the propriety of removing a Cancerous tumor by a surgical operation, our author decidedly recommends that the sooner that this is done, the better;" provided always that the constitution of the patient be treated dynamically both before and after the operation." For the purpose of effecting the removal he prefers the use of Caustics to that of the knife. His reasons we give in the following words :

"If we consider that a chemical caustic acts slowly for several days in succession, becomes infiltrated pretty deeply into the flesh, passes in part into the healthy tissues, pursues the morbid product even into its most extreme recesses, is more or less completely absorbed, and acts as a general sedative, at the same time that it removes the mischief, hit by bit, (à plusieurs reprises) until a process of healthy granulation is established; if, moreover, we reflect that this destruction is accompanied with a dynamic ataxia, which the mineral poison produces upon the morbid part, and that the existence of this is an obstacle to the hypersthenic re-action of the general system-a re-action which is invariably the result of a cutting operation, and which, without fail, must accelerate the progress of the diathesis-we may readily understand the motives which have led me to prefer the use of caustics to that of the knife, whenever it is possible; or to join both means together, if such be ever deemed necessary. Experience has proved that more advantageous results have been obtained from the use of caustics than from that of cutting instruments; and we verily believe that these results would be still more favourable, if a judicious internal treatment had been adopted at the same time."-Annales de la Therapeutique.

ON THE FORMATION OF THE AMMONIACO-MAGNESIAN PHOSPHATE IN PUTRESCENT MATTERS.

Numerous experiments have proved that, whenever any animal matter begins to putrefy, there are formed in it crystals of the ammoniaco-magnesian phosphate, which are discoverable by the use of the microscope. By this simple method they may be readily seen in putrescent urine, for example; but, not so, if this fluid be deprived of its fibrine by the addition of corrosive sublimate; then no trace of the crystals is to be found, even after four weeks of putrefaction.

If heat be employed to get rid of the coagulable contents, the crystals are formed only very slowly. They are abundant in the products of Nephritis, and Catarrh of the bladder. Dr. Zimmermann has discovered them also in the debris of carious teeth, in the exsudation of pleuro-pneumonia, in the nasal mucus, in ordinary purulent matter, in the fæcal discharges-more especially of those animals which have a long intestinal canal, and which consequently retain for a length of time the food on which they live.

As often therefore as crystals of the Ammoniaco-magnesian Phosphate are found in any of the secretions of a patient, we may fairly presume that there exists a putrid decomposition of animal matter. It is only in this manner that we account for the presence of this salt in the alvine discharges in Typhus fever, and in the urine of persons affected with paralysis of the bladder.-Wochenscrift fur die gesammte Heilkunde.

CESARIAN OPERATION ON A DEAD WOMAN: CHILD SAVED.

M. Loweg was called to the assistance of a pregnant woman, who had been long ill she died very shortly after his reaching the house. The Cæsarian operation was immediately performed, and the child with the placenta was extracted without delay. It seemed on removal to be dead; but it had evidently continued to live up to the very moment of the mother's death. It was straightway put into a warm-bath, and artificial respiration was steadily employed. After a quarter of an hour's perseverance with these means, the pulsations of the heart were first discoverable, and soon afterwards the child began to breathe. It lived for several months.

Remarks. It is indeed very rare that an infant, extracted from the uterus after the death of the mother, has been known to live. It deserves to be generally known that, when such has fortunately been the case, the success has usually been owing to the steady use for some time of the means employed in the present case; viz. of the warm bath and insufflation of the lungs by applying the lips directly to those of the infant, and breathing warm air into its chest --thereby keeping up an artificial respiration for a considerable period.—Ibid.

BICEPHALOUS CHILD: LIGATURE OF ONE OF THE HEADS.

On the 31st October, 1843, M. Buhring was called to see a new-born infant, on the back of whose head there was a large tumor, that was in a great measure covered with hair. On an attentive examination, he found that the child had a small head, having the forehead flattened as in the ape, the anterior fontanelle normal, the posterior one very large and covered with a thin skin; a part of the left parietal and of the corresponding occipital bone seemed to be awanting at the place where they join to form the lambdoid suture; the face was regularly formed, and the other parts of the body were well developed. On the occiput at the side, and a little to the right of the fontanelle, was situated the tumor, which was attached by a pedicle of an inch and a half in thickness; it seemed to be, as it were, a second head, that was actually larger than the true head of the child. This pseudo-head had the face turned to the right side; it had an ocular cleft, but without any eyeball, a projection in the site of the nose, and a depression in the place of the mouth. No distinct bony plate could be felt in any part; and indeed the round mass appeared to be formed by an elastic hairy scalp, which was of an almost cartilaginous firmness in some points. At the back part of this sort of Mole, there was a spheroidal mass, of a very red colour, evidently fluctuating, and yet insensible on pressure; although every other part of the tumor was so tender, that the infant began to cry on the gentlest touch. It was quite otherwise when the pedicle, which joined the two heads together, was compressed; there the sensibility was null; but symptoms of cerebral congestion appeared, if the constriction was increased beyond a certain degree.

M. Buhring determined to remove the tumor by ligature; but, first of all, he made an incision into the part which presented a sense of fluctuation. Between four and five ounces of a transparent yellow serosity were discharged; and, on separating the lips of the wound, he saw distinctly at its bottom two normal cerebral hemispheres, provided with regular medullary convolutions. When the ligature around the pedicle was tightened, the breathing of the infant, which had hitherto been quite tranquil, became hurried and laborious, the vessels of the face and head, especially the external jugular vein, very highly congested, and the pupils dilated. Some blood was therefore taken from the jugular