is evident that causes must exist for preventing persons who might be thus so mutually serviceable coming oftener into contact. The leading one is doubtless that indicated by Dr. Conolly, namely, the unintermitting attendance usually required at the hands of the attendant, no provision whatever being made for relaxation or temporary cessation of duties. Few minds possessed of the sensibility which constitute their most valuable property, could long withstand the harassing wear and tear incident upon their incessant occupation, or alternated with intervals of mere listlessness. Occasional breaking up of the routine of duties by the enjoyment of the society of the sane, healthful recreation, or change of occupation, is essential if the mind is to be maintained in its pristine vigour. It is evident that this cannot be accomplished as long as one individual alone has the charge of the insane patient; and we think it highly detrimental to the interests and comforts of the one and the other that he should ever be permitted to have this. Moreover, a person qualified as we have supposed would properly decline performing many menial offices now expected at the hands of the attendant. He should, therefore, always be provided with a subordinate for such purposes. This would entail an expense, not to be defrayed by other than the very wealthy, and would render the maintenance of the patient otherwise than in an asylum generally impossible. And we are convinced it is always undesirable he should be otherwise placed than under the roof of such an establishment; but we believe that the directors of this would find their account in employing a higher class of attendants, remunerating them better, and adjusting their duties more judiciously.

Religious Services.-Dr. Conolly, Dr. Brigham, and others of the most enlightened medical officers have frequently borne testimony to the value of these when subordinated to the other portions of the general plan, pursued with temperance and caution, and only to the extent sanctioned by the physician. Indeed, the good results which have attended their performance have been far greater à priori than might have been expected, seeing that so large a portion of the patients in the asylums of this country, and especially in America, have been originally rendered insane by perverted religious tenets and fanaticism. Still, every thing depends upon the prudence with which this instrument of improvement is wielded; for if it be placed in the hands of a rash intermeddling or conceited man, great evil will result. We quote some passages from a just appreciation of a Chaplain's various duties from the pen of Rev. T. Gallaudet, Chaplain of the Retreat at Hartford, U. S.

"So long as the insane have any exercise of their reasoning faculties left, and any moral and religious susceptibilities to be appealed to, (and no inconsiderable portion of them retain more or less of these faculties and susceptibilities, and some of them in a striking degree), so long Divine Truth, with its higher motives and consolations, will be found eminently adapted to the exigencies of their unfortunate condition, and one of the most salutary and efficacious means of cure. To what extent the influence of this Truth can be beneficially employed, time and a careful experience will show. Its effects should be critically noticed, and compared at different Institutions.

"In exhibiting these views, however, it ought to be stated, that the Chaplain by no means regards it the part of a wise performance of his duty, in his per

1847)

Religious Services-Instruction.

135

sonal intercourse with the patients, to confine himself to conversation on religious topics merely. He endeavours with the general counsels, and often with the specific suggestions of the physician, to adapt the mode of this intercourse to the peculiar exigencies of the case. He appears among the inmates as their sympathizing friend. He exchanges with them the customary civilities of social life. He listens to their conversation, and lets them see that he is interested in it. He often introduces other than grave and serious subjects, adapted to afford rational instruction or innocent enjoyment; nor can he discover that, in doing this, he is exposed to any disparagement of the proper dignity of his office, by the want of courtesy or respect of those whom he seeks to benefit. It is, indeed, by pursuing such a course, that he hopes to avail himself of the suitable opportunities when they offer, and they not infrequently do offer, of presenting, in the most favourable manner, the simple and consoling truths of the Gospel.

"The good order, too, of such a numerous household, including the officers of the Institution, and others who are engaged in the management of its internal affairs; the conscientiousness, faithfulness, and kindness with which their various duties should be discharged; and the diffusion throughout the whole establishment of that spirit of self-denying benevolence which the Gospel teaches and inspires, are best promoted by constantly bringing before their attention, and commending to their cordial acceptance, as the rules of their conduct, the principles, the motives, and the encouragements contained in the oracles of Divine Truth."

A clerical officer actuated by these enlarged views must be an invaluable coadjutor to the physician, and is well deserving of the encomium passed upon him by Dr. Butler.

Instruction. We can sympathize with the regret with which Dr. Conolly views the ill-judged suppression of the schools at Hanwell. Wherever they have been established in this country, in France, or in America, the testimony is universally in their favour as powerful means for ameliorating the condition of the patients. From the last Lancaster Report we extract the following.

"Exclusive of day-schools for the idiotic, an evening class for reading, writing, and arithmetic has been established in each ward, under the superintendence of the matron and chief-attendant, with such assistance as the ordinary attendant can bestow, aided in many cases by the better educated portion of the patients. A great number of the inmates take a lively interest in the proceedings, and in many, a marked improvement is obseryable. The day-schools are conducted on somewhat the same principle as that adopted in infant schools, and it is most gratifying to observe the favourable impression produced even on the idiotic mind by well-directed and persevering efforts, where, to the casual observer, all prospect of educational benefit would appear to be utterly hopeless."

Dr. Brigham, whose establishment possesses the great advantage of having attendants specially devoted to the instruction and amusement of the patients, says of the Schools:

"Our confidence in their utility has been increased by experience and observation. Many cases, we believe, cannot be improved, but by arousing and calling into exercise the dormant faculties of the mind. Hence we have found our schools particularly beneficial to the demented and those approaching that condition. In such, the active state of the disease, which originated the mental disturbance has passed, and left the brain and faculties of the mind in a torpid state. In these cases, medicine is in general of no use, and as we have said, they cannot often be much improved, but by exercising the faculties of the mind.

But others are also benefited by devoting a portion of every day to mental improvement. To those who are nearly or quite well, and who remain with us for fear of relapsing at home, or for other reasons, our schools afford enjoyment, and often means of improvement, which they highly value. Those that are uneasy and nervous, that are constantly restless and disposed to find fault and to annoy the attendants, and quarrel with all about them, because they have nothing else to occupy their minds, are also much benefited by the exercises of a school. We are every day surprised at the good effect they have upon this class of patients." P. 35.

Dr. Conolly concludes his work with some most excellent observations upon the proper officering of asylums; and ably illustrates the evils of the present plan of subdividing authority among the physician, matron, and governors. His advice, based upon long experience of suffering under the inconveniences he exposes, calls for the serious attention of all those who think that future attempts at ameliorating the condition of the insane should not be liable to risk of failure from intermeddling of well-meaning but ignorant lay-men, though these be "justices of the quorum.”

Appended to Dr. Brigham's Report are some observations upon the Prevention of Insanity. He truly enough says that, if the predisposing causes were more sedulously avoided, that attacks and relapses of this dreadful disease would be far less frequent; and he seems to think that the public only need advising upon the liability of its being hereditarily transmitted or induced by faulty education and habits of life detrimental to health. Were this all, certainly to no one could we point as so capable of giving such advice as the learned author of the Influence of Mental Cultivation in inducing Insanity: but, alas! those who have to do with the realities of this bustling world, too soon become acquainted with the invincible carelessness or indifference of the public in respect to all hygienic precautions, and the too frequent impossibility or nullity of such amidst the increasing turmoils, struggles, and reverses of the present state of society. That insanity is upon the increase in this country, in France, in Germany and the United States can excite no surprise in the mind of those who are attentive spectators of what is passing around them.

With Dr. Brigham's opinion upon one other point touched upon by him we entirely agree, namely, that medical men in general practice do wrong to neglect the study of insanity, leaving it thus entirely in the hands of a special class of practitioners, and even rendering themselves incompetent to decide upon when the assistance of these can be most beneficially sought for. The earlier symptoms, are for this reason often overlooked or mistaken, and invaluable time lost, when by some overt act the patient makes patent to all the world that which the eye of science ought long since have provided for. Moreover, if preventive counsels are to be of any avail, they will be so by being specifically adapted to individual cases. You may furnish the public with the best popular treatises upon the subject, but they are unable or unwilling to correctly apply the principles these may contain. Our readers are aware that one of the highest claims Dr. Conolly has to the gratitude of the profession, is his earnest endeavours to diffuse information by his valuable clinical lectures at Hanwell.

We had intended citing one or two papers from the "Journal of Insanity," but have exhausted the space at our disposal.

1847]

Smith on Fractures and Dislocations.

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A TREATISE ON FRACTURES IN THE VICINITY OF JOINTS, AND ON CERTAIN FORMS OF ACCIDENTAL AND CONGENITAL DISLOCATIONS. By Robert William Smith, M.D., M.R.L.A., Fellow of the Royal College of Surgeons in Ireland, Lecturer on Surgery at the Richmond Hospital School of Medicine, &c. &c. Octavo, pp. 314. Dublin: Hodges and Smith, 1847.

We know of no class of cases more perplexing to the practitioner than the injuries considered in the work before us. Öften have we seen surgeons even of considerable experience at fault, or at a loss to make out the exact nature of the lesion in cases of injury connected with a joint, and though much has been written on the subject, there is no work in which it has been satisfactorily treated of. Boyer, Sir A. Cooper, and Dupuytren have indeed done a good deal in clearing away the obscurities connected with fractures in the vicinity of the articulations, but there is a remarkable discrepancy in their accounts of the symptoms of many of these injuries, which can only be accounted for by unsettled and imperfect views of their pathological characters. We think, therefore, that Mr. Smith, who is known, by his contributions to the Dublin Medical Journal, to have devoted much attention to this important subject, required no apology for submitting his views to the notice of the profession.

Chapter I. is on the Diagnosis and Pathology of Fractures of the Neck of the Femur. After describing the ordinary symptoms of this injury, Mr. Smith notices the difference of opinion which has existed, and indeed still continues, as to the amount of shortening of the limb which occurs in the two varieties of this important lesion. Upon this question the most eminent surgeons of modern times are directly opposed to one another. Sir Astley Cooper, Amesbury, Chassaignàc, Vidal (De Cassis), and others, maintain that the shortening is greater in the intracapsular fracture than in the extracapsular. Upon the other hand, Desault, Boyer, Dupuytren, Cloquet, Earle, Stanley, &c., have stated, that the greatest amount of shortening accompanies the fracture external to the capsule. How are such conflicting statements to be reconciled?" In discussing this question our author very properly limits his observations to the retraction of the limb, which immediately succeeds the receipt of the injury; for this is the period at which it is most important to form a correct diagnosis. The chief circumstance, according to which the degree of shortening varies in cases of intra-capsular fractures, is, the amount of laceration suffered by the fibrous covering of the neck of the bone, which Mr. Smith rather inappropriately terms the "cervical ligament of the femur."

"If the force which acts upon the neck of the femur be inconsiderable, and, as it were, exhausted, after producing the fracture, this ligament may escape uninjured, or nearly so. In such a case, the retraction of the limb will be very slight, and will be at its minimum when the fracture has traversed the bone obliquely from the inferior part of the head of the femur downwards and outwards. When the cervical ligament remains nearly entire, it not only limits the retrac

tion of the limb, but it likewise becomes the sole medium through which a vascular communication is maintained between the fragments; it is, therefore, very important to observe the utmost caution in examining the limb; and if the existence of fracture of the neck of the femur is rendered evident by the presence of the other symptoms which characterize this lesion, we should, I think, abstain from instituting such an examination as is necessary to produce crepitus. In doubtful and obscure cases, this examination should of course be cautiously made, but I perfectly coincide with the opinion of Boyer, that, in the majority of cases of fracture of the neck of the femur within the capsule, the nature of the injury is sufficiently indicated by other symptoms." P. 8.

No doubt, as stated by Boyer, and indicated in a case of Mr. Stanley's, which is quoted by the author, much injury may result from a rough examination of the injured limb, but without either shortening or eversion, which may not be present when the fibrous covering is entire, the nature of the case would not be so clear as to justify the surgeon in dispensing with an examination of the limb.

Among the causes which limit the retraction of the limb in cases of intra-capsular fractures, Mr. Smith does not omit to notice the powerful capsular ligament which so closely embraces the articulation. He very properly controverts the statement of Sir A. Cooper, that when the bone is broken within the capsule, the leg becomes from one to two inches shorter than the other, siding on this point with Mr. Earle and Boyer, who never witnessed such an occurrence. But when the fracture is external to the capsule and not impacted, there is but little to prevent the full force of muscular action upon the lower fragment of the bone, while, at the same time, the upper is depressed by the weight of the body, so that, from these two causes, a degree of shortening may be produced equal to, or even greater, than the entire length of the neck of the bone.

Again, we meet with cases in which the shortening of the limb is not by any means decided or evident for several days after the receipt of the injury: in such instances it usually happens that the muscles have been, to a certain extent, paralyzed by contusion; but according as, under the influence of rest, &c., they regain their power of contracting, the limb becomes slowly and gradually shortened, and this independent of any process of absorption. A third class of cases occur, in which the retraction of the limb, having been at first scarcely perceptible, at the expiration of a few weeks becomes very considerable, owing to the rapid absorption of the neck of the bone. In the case of Margaret Myler the amount of shortening was at first only a quarter of an inch, but at the end of six weeks amounted to one inch and a half. Lastly, examples are sometimes seen in which the limb retains nearly its natural length for many weeks after the receipt of the injury, and then a very decided and, comparatively speaking, considerable degree of shortening occurs, not gradually, but suddenly. In these cases the diagnosis is somewhat obscure; the cause which has produced the fracture is comparatively slight, and the patient has not made any attempt to use the limb after the receipt of the injury; the eversion of the foot is by no means so well marked as when the retraction has occurred early; the patient is, it is true, unable to raise the limb en masse, but this may be owing to the effects of contusion upon the muscles; in fact, in cases such as those to which I allude, there may be at first neither shortening of the limb to any appreciable extent, eversion of the foot, nor any change in the position of the trochanter; and therefore, unless we can ascertain crepitus, it is most difficult to decide whether the neck of the bone be broken or not; and if we fail to elicit crepitus, the more prudent course is to withhold our opinion until time shall more fully develop