347

by Mr. Hawkins as to the after-results of the system. He hadseen the operation performed in six cases. In two instances itwas upon the elbow-joint after a fracture of the internal con-dyle, in two or three upon the hip-joint, and in one or twoupon the knee-joint. In none of these cases did a bad symp-tom present itself. The patients were placed fully under theinfluence of chloroform, and in one instance the operation wasperformed a second time. In consequence of the successfulissue of these operations, he (Mr. Wells) had been encouragedto resort to the proceeding in a case in which the internal con-dyle and the humerus having been fractured; the limb wasfirmly flexed upon the arm. It yielded, however, to extension,and motion was re-established without any ill consequenceswhatever.Mr. HUTCHINSON bore testimony to the little danger which

was incurred in breaking down adhesions of the knee-joint-anoperation frequently performed in the larger hospitals of Lon-don. In only one or two cases had he seen any considerableamount of inflammation follow the proceeding. He could notgive a decided opinion as to whether the plan recommendedoffered any material advantages over the one in common useat the Orthopaedic Hospital. He thought, however, in his ownpractice that he should prefer the latter mode of dividing thetendons, and procuring gradual extension by an apparatus.Mr. Brodhurst had referred to excision in some of his cases-an operation which had never suggested itself to him (Mr.Hutchinson)-an operation, in his opinion, only justifiablewhen acute disease was going on, as the alternative of amputa-tion.Mr. BRODHURST had brought the subject before the Society,

in consequence of a statement made at a medical meeting inVienna by Baron Dumreicher, that the division of tendons wasnecessary, and that extension alone was required in cases ofpartially anchylosed joints. He believed, from the cases ofLangenbeck and Louvrier, that the tendons ought to be dividedin cases where great rigidity existed. He had seen no evileffects from extension, except a rather serious inflammation inone case; but this subsided, and motion was established. Theauthor had not found it necessary to divide the ligaments,though there might possibly be cases in which that operationwould be expedient. He should hesitate to extend the limbimmediately after the use of the knife. He had only hadthirteen cases, all of which had terminated successfully. Inone of his cases resection had been suggested, and it was onthat account that it came under his care.

MEDICAL SOCIETY OF LONDON.

SATURDAY, MARCH 28TH, 1857.MR. HIRD, PRESIDENT, IN THE CHAIR.

Mrp. BRODHURST read a paperON THE TREATMENT OF LATERAL CURVATURE OF THE SPINE.

The author commenced by stating the various causes of lateralcurvature, and he showed that some varieties of curvature arealone amenable to treatment; he affirmed that it was not diffi-cult to discover the cause of curvature, and he pointed out themeans by which an accurate diagnosis might be made. Theseseveral points were elucidated by means of casts. He thenalluded to primary and secondary curves, and explained howto distinguish the primary curve. Through ignorance of thesequestions, it was customary to treat the dorsal curve alone,whether a primary or a secondary curve; and, consequently,the lumbar curve was frequently increased by attempting toremove a compensating dorsal curve. He showed that a com-pensating curve was an effort of Nature to restore equilibrium,and that though it were removed, the primary curve and thecause of distortion would remain. Much scepticism, he said,existed with regard to the utility of spinal instruments, whichhad been occasioned by the application of instruments to everyform of curvature, without inquiry being made as to the causeof distortion, as though every form of spinal curvature could beremoved. He alluded to the unphilosophical mode of at-

tempting to remove a rigid spinal curve by lateral pressure,and asserted, that to overcome such a curve by such means wasa physical impossibility. The result of such treatment was toinduce flattening of the ribs, but no diminution of the spinalcurve. Instead of lateral pressure alone being employed, heshowed that it was necessary to unbend a spinal curve ; andthat although slight curvature might be removed by supportonly, a rigid curve required to be unbent. The author thendescribed the manner in which this was to be effected, and ex

plained the spinal apparatus and its action as follow :-" Theinstrument consists of a band fitting accurately to the pelvis,from which rise two lateral uprights, the heads of which rest inthe axillae, and support the shoulders. These uprights elon-gate, so that they may be raised to any desired height; theyalso move in the segment of a circle at their junction with thepelvic band: consequently one or both may have a perpen-dicular or an oblique direction. Springing from the centre ofthe pelvic band is a perpendicular steel bar, (vertebral stem,)which rises to the upper extremity of the dorsal curve. Thisstem is united by a transverse band, (scapular band,) with thecrutches. Thus a solid frame is produced, which cannot betilted by any amount of pressure. The vertebral stem supportsthree levers, all of which are moved by rack-and-pinion joints.The lowest of these gives attachment to the lumbar webbingband; to the middle lever is attached the dorsal webbing band,and the upper lever is connected with the shoulder ring. Thelumbar and dorsal webbing bands are further attached in frontto two perpendicular levers, which are placed on the anteriorsurface of the pelvic band, and which, as the other levers, aremoved by rack-and-pinion joints. Now, when the lumbar isthe primary curve, its concavity is supported by the lowestwebbing band, and the dorsal band is applied obliquely insuch a manner that it shall act on the inferior extremity of thedorsal curve by uplifting it. This action of the instrumentwill tend to depress the pelvic band. A webbing band, fast-ened to a lever in front, and to the pelvic band behind, passesover the highest ilium. This, by its action on the lumbarcurve, tends to restore the horizontal position of the pelvis;and the combined action of these four bands is to unbend thelumbar curve. When the dorsal is the primary curve, its con-vexity is also supported by a webbing band, while the lumbarband is applied to the upper extremity of the lumbar curve toact upon it obliquely in a downward direction, and the upperextremity of the dorsal curve is equally acted on by theshoulder sling, which, embracing the scapula, and lying uponthe ribs which correspond to the extremity of the dorsal curve,acts upon them to unbend the curve. Thus the convexity ofthe curve being firmly fixed, there is power to uplift and de-press the extremities of the curve, which cannot fail to unbendit if the positions now laid down are attended to. When muchrotation of the vertebras is superadded to lateral curvature, ametal plate, movable with rack-and-pinion joints, is attachedto the perpendicular vertebral stem of the instrument ; bymeans of which adequate pressure can be made from behindforwards.

Mr. HU1’T observed, that the age had not been mentioned byMr. Brodhurst at which he believes treatment to be no longerpracticable; and he inquired the ages of the several patientsto which reference had been made, and from whom the castswhich were exhibited had been taken.Mr. HARRISON remarked, that it had been stated by the

author of the paper, that three-fourths of the cases of lateralcurvature of the spine arise from increased muscular action,and from debility; and inquired if such cases could with safetybe treated at any period without mechanical support, or, ifnot, how soon support ought to be employed.

Dr. RYAN had used a similar instrument to that now ex-hibited with great advantage, and he remarked that the healthof the patient was not injuriously affected by a portable in-strument, as was too often the case when the recumbent posi-tion was long maintained.Mr. ADAMS doubted whether spinal instruments of any kind

were useful after twenty-six years of age; and he believedthat a pliable curve could alone be acted on by mechanicalmeans. He had no faith in any power to unbend a rigidcurve, or to act upon such a curve by lateral pressure; and hethought that gymnastic exercises and the recumbent positionwere more useful than any instrumental means that might beadopted. Yet he admitted that cases existed in which sup-port was necessary to relieve pain; and he cited a case inwhich considerable pain had been relieved by uplifting the de-pressed ribs. He doubted if pressure could ever be borne inthe axilla, for he had always found that such pressure was fol-lowed by swelling of the extremity. He observed that theinstrument now exhibited was different to that originally con-structed by Mr. Errard, and inquired whether the alterations

B had been made by Errard.Mr. PoTTS could not subscribe to the opinion of Mr. Adams,

that instrumental interference was useless. He had seen cases,especially from fifteen to twenty years of age, in which greatadvantage had been derived from the use of spinal instruments.Mr. ADAMS remarked that slight pliable curves might be re-

moved by means of apparatus, and reiterated his opinion thatrigid curves could neither be unbent nor affected bv lateral

348

pressure. He stated that he had lately examined a spine inwhich four curves existed, where neither pain nor other incon-venience had ever been experienced. The treatment withwhich he should be content, in the instance of a single curve,would be, if possible, to transform it into four short curves. He thought that, if such a result could be obtained, more benefitwould be derived than from any other mode of treatment. Noill result could occur except some shortening of the trunk.

Dr. CHOWNE was sorry to have heard so much said againstthe utility of spinal instruments. He had seen much advanttage from their use, and thought that, although the correc-form of apparatus might not yet perhaps have been discovered,that apparatus was likely to prove most useful which encasedthe patient in the most efficient manner, and which affordedthe most support.Mr. BRODIIURST replied that the ages of the cases to which

he had referred varied from sixteen to thirty-eight years, andthat the three cases to which he had especially directed atten-tion were taken at eighteen years of age, twenty-three years,and thirty-two years respectively. The improvement whichhad taken place in these cases was shown by the photographswhich had been subsequently taken, after eight months andafter fourteen months of treatment. These cases were instancesof very severe distortion, and yet it was shown what treatmenthad been able to effect. He was surprised to hear the opinionexpressed by Mr. Adams with regard to the benefit whichmight be expected from mechanical treatment, and expressedhis belief that, when the several curves were properly acted on,distortion might generally be overcome, but that distortioncould not be removed by acting only on one curve. Supportcould not be applied too early when a spinal curve had beenformed; but it was not necessary to use an elaborate instru-ment when curvature was very slight. Support to the spineand to remove the weight of the shoulders was in such casessufficient. All the cases referred to had been treated on theprinciple of unbending the curve, by means of an instrument ofexcellent construction made by Mr. Bigg. This instrumentwas elaborated from one far less perfect, which was constructedby Mr. Errard. Age was a very imperfect indication as to therigidity of spinal curves. At sixteen, or even earlier, muchrigidity might exist; whilst, on the other hand, a curve mightremain pliable until thirty or thirty-five years of age. Painalso was very variable; it existed both with long ancl withshort curves.

PATHOLOGICAL SOCIETY OF LONDON.

DR. WATSON, PRESIDENT, IN THE CHAIR

Dr. MARKHAM exhibited a specimen ofOPEN’ FORAMEN OVALE.—LOUD CrSTOLIC BRUIT : WHAT WAS

ITS CAUSE? TUBERCULOSIS OF THE LUNGS.

The little girl, a delicate child, aged four, in whom these con-ditions were found was seen’by him on Feb. 8th. He heardthen a loud cystolic bruit along the base of the heart, in thewhole sub-clavicular region, but it was scarcely audible belowthe nipple. On the 17th the child was seized with violentconvulsions. The following day the bruit was heard louderand rougher than before; it was now audible over the wholeprecordial region, and up the right of the sternum, also overthe upper half of the interscapular space on both sides of thespine. The respiratory murmur was everywhere loud andclear; the percussion good; no râles perceptible. The respira-tion was easy, the skin hot, the pulse rapid; there were con-vulsive twitchings of the left shoulder and arm; the child wasdrowsy and stupid. The mother now said that the child hadbeen always subject to cold, bluish feet, and pointed out somebluish veins around the finger-nails. These were the onlysymptoms, very slightly marked, of cyanosis. Necropsyshowed that the heart was perfectly sound, save in respect ofhaving an open foramen ovale. Was this opening the cause ofthe bruit ? The question excited some discussion. Drs. Quainand Peacock knew of no case of open foramen ovale in which abruit had been heard during life where some other abnormalcondition-e. g., constriction of pulmonary artery-had notco-existed. They could give no account of the bruit; it seemedanomalous. Dr. Markham argued that the bruit was formedat the open foramen ovale, and that the fact was not to be re-jected simply because such a bruit had not yet been recognisedin auscultation. His reasons were: that there was no othercause to which the bruit-on several occasions most carefullyobserved-could be attributed; that there was nothingin the formation of the Darts involved repugnant to

the idea of the formation of such a bruit. Thus, the bruitbeing coincident with the cystole of the ventricles, necessarilyoccurred during the diastole of the auricles. Certainly such abruit could not conceivably arise during the auricular cystole,for the foramen ovale being open, the blood in both auricleswould then be subjected to a like pressure, and therefore nointercurrents could occur; but during the diastole, the blood,rushing into the auricles from the large venous trunks, mightreadily pass through the abnormal opening, and throw thevalve into such vibrations as would occasion an audible mur-mur. And the valve, in this case, had this peculiarity : it wasattached to the upper and lower parts of the opening, on theleft side of the septum, but was free elsewhere, and wouldallow a current of blood to pass readily from the right to theleft auricle, and then be thrown into vibrations. The objec-tion that the current of the blood in such case would not bestrong enough to produce a bruit, is answered by the fact, thatweak currents of blood will occasion loud bruits under certainconditions; witness the occasional roaring bruit produced bythe gentlest pressure of the stethoscope on the cervical veinsof the auasmic, and witness also the loud bruit sometimes heardeven over the radial artery. That such a bruit is so rarelyheard during life may be explained by the fact, that whereother abnormal states of the heart do not co-exist, there is nocardiac disturbance, and therefore no examination is made ofthe heart during life to ascertain the fact. And why, again,should it be assumed that in cases of open foramen ovale, asso-ciated with other defective states of the heart, in which mur-murs were heard during life, that the murmurs always havetheir origin in those other defective conditions, and never inthe open foramen ovale ? For such reasons, Dr. Markhamthought it more rational to attribute the bruit to the openforamen ovale than to acquiesce in the proposition that someinexplicable mystery involved the subject. Another fact of

great interest was observed in this case in connexion with thelungs: seventeen hours before death a most careful examina-tion could ascertain nothing abnormal in their condition, andyet miliary tubercles were found thickly scattered throughevery lobe of each lung. The possibility of such a thing is ad-mitted, but its demonstration is rare. "Solitary tubercles,’’says Skoda, ’’ of themselves produce not the slightest changein the percussion-sound; we can only surmise their existence."The fact is readily explicable. The percussion sound is un-altered because healthy, air-containing tissue intervenes be-tween the tubercles; the respiratory murmur is clear becausethe air enters freely; there are no rales because there is noexudation yet thrown out. The case therefore proves that theabsence of physical signs is no proof of the absence of tuberclein the lungs, and consequently condemns as hypothetical theexistence of so-called pre-tubercular stages of phthisis, and thedeductions drawn therefrom. It seems also to prove the exist-ence of a species of cardiac bruit hitherto unrecognisecl byauscultators.

Dr. THEOPHILUS THOMPSON asked if there was any bluenessof the surface ?

Dr. MARKHAM.-The child had always cold feet 113 d bluenessof the nails, and some degree of cyanosis.

Dr. CAMPS had a case of cyanosis, some years ago, in a girltwelve years old, with a marked and constant bruit.

Dr. OGLE had examined 100 children, and found the foramenovale open in the greater number; there was no cyanosis inthese cases.The PRESIDENT asked if the miliary tubercles were the same

as is ordinarily seen.Dr. MARKHAM said there was no doubt of it.Dr. HEWETT confirmed Dr. Markham in the difficulty of

diagnosing tubercles in children.Dr. QUAIN said the bruit in cyanosis would depend upon the

cause producing it. He heard with consternation that such aquantity of tubercle could exist without physical signs.

Dr. THEOPHILUS THOMPSON, on looking at the lung, thoughtthere was an average quantity of air present, which wouldgive fair percussion, but he was surprised the respirationsounds were perfectly natural. The presence of an openforamen ovale is not enough to produce a bruit; anything elseobstructing the blood will do it. He doubted if the mere

passage of blood through the foramen ovale could produce sucha loud bruit as described by Dr. Markham.

Dr. HARE read a similar case, with normal resonance on per-cussion, and a like condition of lung.

Dr. PEACOCK said that after the length of time which thediscussion of Dr. Markham’s communication had occupied, hewould trespass on the time of the Society only for a very shortperiod. Cases like that mentioned by Dr. Camps, in whichthere was intense cyanosis, were, in a very large proportion.