instance foliated piece gives way, on the pressure of the instrument. I do not, however, suffer it to be removed immediately on discovering its separation from the body of the Tibia; but generally let it remain in its situation two or three days, in order to give sufficient time for its being completely disengaged, that it may be removed with less danger of being broken. I then complete the removal in the most gentle mauner; sometimes by the forceps, sometimes by passing either the one side of a pair of forceps, or a director, under it, as circumstances may dictate.* Having proceeded thus far, my attention is next directed to the removal of the loose pieces of bone within the cancelli. In almost every in which the process above described has been followed, I have found this bone at perfect liberty. But before I attempt its extraction, I always introduce a probe, in order to ascertain its exact position. In most of the cases which have come under my care, it is readily felt by. the probe; but the practitioner should be prepared to meet with some disappointment here. There are cases, in which, from its smallness, it is not only extremely difficult to find the imprisoned piece, but even to discover any vestige of it, on the first examination. In three cases 1 found it so small as to require a very nice management of the probe to feel it; in two of these cases, the loose piece was found immediately after the enlargement of the aperture in the Tibia was accomplished; in the third case, it was not found till two days afterwards. Out of the whole number of cases, which have occurred in my practice, I can advert only to one in which I have searched in vain for it: nor do I feel warranted to conclude, that even in this case there was no such piece ; but rather suppose, that, by its minuteness, it either eluded the search with the probe, or escaped unperceived in the dressings. This solitary instance occurred, before I was aware how very small some of these pieces are found to be. In the three cases I have mentioned, the loose pieces found would have escaped my notice, had I relaxed but a little of that perseverance with which I searched, and any conclusion against their existence, drawn from the disappointment, would, of course, have been erroneous. "After having enlarged the aperture in the Tibia, by the caustic process, already described, and having found the loose exfoliation, I have in almost every case been able to extract it. There has, however, been an instance or two, in which it has been found still too large to pass through the aperture; although it could be moved upwards and downwards, in its bony case. In these cases I have been obliged to adopt the method already described in page 11; viz. of breaking the loose bone into two parts, in order to liberate it from its confinement. Had I not been able to do this, I must probably have been obliged to make use of the trephine. * This exfoliation generally exhibits a very curious appearance. From an examination of seven or eight pieces of bone thus exfoliated, from as many different cases, it is evident that the ulcerative process, at the commencement of this disease, erodes the substance of the Tibia, in this part, to such a degree, as to render the enlargement of the hole, by the caustic, more certain, than it would have been, had the Tibia been of its usual thickness. 3 E (No. 142.) "Having "Having carefully examined all the pieces thus extracted in the different cases which have come under my observation, I have invariably found them to be exfoliations of the interior lamine of the Tibia; no marks of affinity with the external surface of the bone having been found on any of them. I am likewise certain that none of the exfoli ated pieces extracted from within the cancelli, were any part of the exfoliation made by the caustic, for the purpose of enlarging the hole in the Tibia. The greater number of them were ascertained to be within the cavity of the bone, before any caustic was applied to the Tibia. Besides which, I should inform the reader, that the pieces exfoliated by the caustic were removed with so much care, that no fracture of them was likely to occur; and if it had, it must have been perceived. "After I have extracted one piece of bone from within the cancelli, I examine the bottom of the wound with a probe, to ascertain whether there be any more pieces: this I continue to do occasionally for about a fortnight, knowing that no cure can be obtained if any portion of bone be left behind. The hole indeed would fill up with granulations, but a small oozing wound would remain. When the cancelli are cleared of these exfoliations, the wound should be dressed in the most superficial manner, and with the most simple dressings; applying compresses and a roller lightly over them.In the greater number of these cases, the skin is perfectly cicatrized in the course of six weeks, or two months, from the removal of the exfoliated pieces; and the inequality on the surface of the Tibia is generally removed. The scar, indeed, and the external appearance of the leg, is somewhat different, after the cure in these cases, from what I have observed in most others. In a few instances, however, I have seen the wound continue open for several months, after the removal of the bones. In one case, indeed, it continued open nearly two years, during which time a probe could be passed within the cancelli, to the extent of four or five inches; but no material inconvenience accrued from it to the patient during this interval, and it afterwards healed up." Under this treatment, the usual termination of the disease, with Mr. Whateley, has been in a speedy recovery. There have, however, occurred sometimes severe symptoms, which have not only endangered the limb, but have even destroyed the patient. In two cases, in middle aged women in the intervals of child-bearing, the infortunia were most formidable, and the consequences extremely serious.* They are attributed by the author, to a violent use of the forceps in extracting the exfoliations from the cavity of the Tibia; but they are more fairly *These were violent inflammation, attended with great pain, extending itself through almost the whole of the Tibia; and the formation of pus on the surface of its different sides, in almost every direction, as well as within the cavity of the bone. In one of these cases, the symptoms arose to such a height, as to destroy the patient in the course of a few weeks. In the other, the patient survived; but the irritation and inflammation were so great, for the first six months, as at length to leave the Tibia eroded through its entire thickness, a little referrable to the patient's walking considerable distances while under surgical treatment, and serve as a proper warning to those who may have the management of similar cases; and will induce them to confine their patients to the house, if not to the bed, during the treatment, The remaining part of the essay consists of twenty-two cases, with a plate and explanations. The value of this pamphlet arises from its practical utility, and as affording additional information from that best source, an observance of nature, on a disease, though not of frequent occurrence, of great importance. If we differ in some points, possibly of opinion only, with Mr. Whately, we admit in the fullest manner the service this species of medical literature is to the science; where, even if the hypothesis be wrong, the. facts, if correctly observed and faithfully related, afford materials for a more legitimate theory, and more certain conclusions. "This disease," says Mr. Whately, "differs totally from those affections of the Tibia produced by syphilis, as it does likewise from those usually denominated NECROSIS." There certainly are no facts that can induce us to suppose it has a syphilitic origin; but that it is a species or variety of the disease examined and so well described by Mr. Russell, (Practical Essay on a certain Disease of the Bones, termed Necrosis, 8vo. Edin. 1794), and by Professor Weidman, (De Necrosi Ossium, fol. Francfurti ed. Mænum, 1793), there is surely but little doubt. The disease which these writers have described in the advanced period, Mr. Whately has seen in the incipient state; or, possibly, in a mild variety, where only a small portion of bone has perished, but which being confined within a bony sheath, has kept up ulceration, until it has been removed. There are some particulars, however, in which the disease described by Mr. Whately differs from the definition of Necrosis, as given by Mr. Russell. In Mr. Whately's cases there seems to have been simply an exfoliation of the internal substance of the Tibia, which falling down among the cancelli and lying loose, keeps up an irritation and purulent discharge; while in the cases that Mr. Russell denominates Necrosis, a covering of new osseous matter surrounds the dead bone. The period of attack is likewise different. Mr. Russell found Ne little below the knee; where, on moving the limb, a kind of joint was observable. By the use of opium, fomentations, and emollient poultices, (the limb being kept in an horizontal position) the disease gradually abated; and after some large exfoliations from the substance of the Tibia had been thrown off, the use of the limb was restored. crosis to be properly a disease of the carly period of life. "I have never known," he says, (p. 92) " a case of it in which the attack began after the twentieth year, except in cases of Necrosis of the lower jaw. About the age of puberty, or from twelve to eighteen years of age, is the time of life at which patients are most liable to be attacked." Mr. Whately found that in twenty-two cases, eighteen occurred to persons past thirty. We are disposed to think, from some cases that have fallen under our own particular knowledge, as well as from an examination of the numerous sequestra preserved in an anatomical museum of great extent, that Mr. Russell has too much contracted the period in which this disease attacks; and that its depredations in advanced life are not confined to the lower jaw. Professor Weidman gives a plate (Tabula tertia) that so much resembles the plate, and so closely accords with the description given by Mr. Whately, that the identity of the diseases seems very completely established. The mode of treatment here adopted for enlarging the opening in the Tibia, through which to extract the sequestra, does not quite agree with the dexterity of modern surgery: neither does it appear to us adequate to the object. We assert this, subject however, to the correction which the great experience of Mr. Whately can well supply. Svo. A Commentary on the Treatment of Ruptures, particularly in a state of Strangulation. By E. GEOGHEGAN. pp. 95, London, 1810.-HIGHLEY. To deviate from the common path of the profession with safety and success, is not the work of ordinary minds, and he may justly be considered as the benefactor to his art who shall suggest any real improvement in the treatment of a disease which has occupied the attention and the pen of so many eminent writers. The interesting little work before us has, besides its intrinsic merit, a claim to our notice, in as much as the subject was many years since opened in the pages of this Journal. In the year 1800, the author published some observations on this disease, in our 4th volume, and his farther experience has confirmed him in the validity of the opinions he then advanced. The present Commentary on the treatment of Hernia, begins with a detail of the general directions given by different authors to accomplish the reduction by the hand, and after citing the opinions of Mr. Pott, Dr. Munro, Mr. Bell, Mr. Cooper, and Mr. Lawrence, the author says, (p. 28) "When When I consider the talents, and the extensive opportunities which these writers possessed, it is not without anxiety that I contest their opinions; but experience has abundantly shewn that they are ineffectual in practice, and I feel a conviction that they are unsupported by theory. I have given their own words that their full meaning may the more clearly appear, and that my inference may the more readily be under stood. The first objects for our consideration, are the structure of the parts concerned, the phenomena which the disease exhibits, and the pathology which may be fairly induced. When Hernia has taken place in the groin, it has passed through two apertures; that which is next the abdomen, is formed by the tendon of the Transversalis and internal oblique muscles, and a fascia that lines the transversalis; the external aperture is formed by a separation of the tendonous fibres of the external oblique muscles; they are filled up with the spermatic chord in males, and by the round ligaments of the uterus in females; they form an oblique canal, which in old ruptures becomes straight, or nearly so. In crural Hernia, it passes under Poupart's Ligament, through a small aperture, in a tendon formed for the transmission of the femoral vessels; during a length of time it slips in and out of the abdomen uninterruptedly, a circunstance to which I would particularly direct the attention; suddenly after any great exertion of the body, such as lifting a weight, coughing, sneezing, &c. or external injury, it refuses to return into the abdomen; on examination it appears tumified, tense, and inflamed, accompanied with excessive pain, and derangement of the functions of the viscera, and universal disturbance, the inflammation rapidly increases, the distension is prevented by the rigidity of the tendinous aperture, or by the neck of the sac which contains the intestine-hence strangulation. The author then goes on to state, what, however, has been stated by others, but the consequences which he deduces are his own, and important; that the strangulation and its symptoms are not produced by any altered state of the abdominal aperture, and that the inflamation and enlargement of the intestines are the essential points to be considered. He then observes, "From what has been stated, it appears that the indication of cure generally laid down, is not warranted by the nature of the disease, nor of the treatment, namely, to return the Hernia through the apertures by pressure with the hands, because, as mentioned before, it is not the situation of the intestine, it is the enlargement of it which occasions the symptoms, and that state should, in the first instance, forbid the attempt on account of its obvious impracticability." These remarks lead the author to, and prepare the reader for a very material alteration in the treatment of strangulated Hernia in its first stages, which we shall state in his own words. "With the view of affording a satisfactory explanation of the practice which I think ought to be pursued, founded on the principles which I have endeavoured to establish, I shall describe my own manner of treat ing a case, and the order which I think ought to be followed, and |