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Sir, to the one-faculty system, however opposed to it power-ful and influential, but self-interested, individuals may now be,we must come at last,; and, in my humble opinion, the day ofits inevitable adoption is not far remote.Mverpool, January, 1846.

REVIEWS.

Lectures on the Nature and Treatment of Deformities, deliveredat the Royal Orthopaedic Hospital, by R. W. TAMPLIN,F.R.C.S.E. London: Longman and Co. 1846. pp. 267.

THE attempted cure of deformities by operative means isone of the most questionable efforts which have been madeby modern surgery. We say " questionable," because mostcordially agreeing with Mr. Bishop, in his elaborate and ad-mirable papers now in course of publication in THE LANCET,that " myotomy" and " tenotomy" are attacking efects insteadof causes, and are therefore in principle empirical. Theidea of dividing the tendons to remove club-foot originatedwith Thilenius, a physician of Frankfort: the first operationwas performed by his direction, but its success as then exe-cuted was small, so that the operation gained no repute; theconception, however, remained. The next great step wasmade by Delpech of Montpellier. Delpech performed theoperation of dividing the tendo-Achillis with success, and inhis Orthomorphie, published at Paris in 1828, the followingprinciples were laid down:-

.

" A tendon to be divided must not be exposed, and its divi-sion should be made by turning the instrument on one side, sothat the line of the incision may not be parallel to the divisionof the skin; without this precaution, risk of exfoliation of thetendon is incurred.

" Immediately after division of the tendon, the divided endsshould be brought into contact with each other, and kept inthis position by a suitable apparatus during the entire periodnecessary for their union.

" Inasmuch as it can only take place by the intervention ofan intermediate fibrous substance, this substance, before ithas become firm, can, and should be extended gradually andcarefully, until it has assumed a degree of length equal to theshortened muscle." When this degree of extension has been effected, the parts

should always be fixed in the position, and kept so until thenew substance has acquired its requisite degree of consoli-dation."

The great points made out by Delpech, were the mode ofunion in divided tendons by the plastic fibrous matter depo-sited between the divided extremities, and the facility withwhich this might be elongated so as to almost entirely com-pensate for the shortened muscle. The necessity for sub-cutaneous division of the tendons was insisted on by Delpech,but was not carried out to the full extent. In his caseof division of the tendo-Achillis, two wounds, of an inchin length each, were made, and this was, perhaps, the causeof the unfavourable circumstances of the case. Delpech diedyoung, or he would, probably, have proceeded to establish thewhole subject on its present basis. As it is, his great merit con-sists in the recognition of the mode of tendinous union, and thepractical inferences he drew therefrom-namely, that the endsshould be placed in apposition, and allowed to unite, and thatthe uniting medium should subsequently be elongated bygradual mechanical force. Resting at this point, however, theoperation made no increase in reputation, until the subjectwas again taken up a few years since by Stromeyer. It is to

Stromeyer that surgery owes the subcutaneous operation asat present practised, punctures being used in place of con-siderable incisions, a difference which is alleged to abate theseverity and danger of the operation. It is right to be thusspecific, as Dr. Little gave undue importance to the shareStromeyer had in the matter, while Mr. Tamplin has insistedunduly on the merits of Delpech. The idea belongs to

Thilenius; the operative measures originated with Delpech ;but these were enlarged upon and diffused by Stromeyer:

other able men have since assisted in a spreading of ortho-pcedic surgery, and among them Dr. Little holds an honour-able place.

In Mr. Tamplin’s lectures, the various forms of contractionof the lower extremities, the upper extremities, the spinalcolumn, and the head and neck, with the operations whichhave been performed for the relief of each variety, are dis-cussed at considerable length. Mr. Tamplin chiefly treatsthe subject as a branch of operative and mechanical surgery.Yet his fitness for the task is more than doubtful. He dis-

plays a very imperfect knowledge of the mechanism of thehuman fabric; and he has taken no notice of the highly in-jurious effects of cutting paralyzed muscles, which Malgaigne,in papers read before the French Academy, has proved tofollow that operation. But on orthopcedic surgery in its

higher relation-namely, to the physiology and pathology ofthe nervous system, even Mr. Tamplin looks with hopeless-ness ; indeed, in this respect, his work is a retrogression fromthat formerly published by Dr. Little. Bones may be movedout of their place, tendons may become stiff, and musclesshort and contracted, but they are merely agents; the ner-vous system is the master-power to the organs of locomotion.In one place, Mr. Tamplin remarks :-

" Our knowledge of the functions of the nervous system islimited, and this state of our ignorance disqualifies us fromgiving any satisfactory explanation, as well of those defor-mities which arise without apparent interruption to the

general health, as of those formidable and fatal affections,tetanus and hydrophobia. On none of these affections hasphysiology or pathology yet thrown any light, although bothhave been the study of many able members of our profession.We cannot, therefore, reasonably hope, whilst the cause ofthe more palpable and striking, and serious nervous disorders,still remains involved in mystery, that the less remarkableand the milder derangements which sympathetically occasionparalytic deformities should be easily traced and compre-hended."—p. 28.

Other quotations to the same purport might be made. Wemaintain, on the contrary, that a flood of light has of late yearsbeen thrown on the motor diseases of the nervous system,tetanus and hydrophobia included. It is Mr. Tamplin’s mis-fortune if it have not reached him; but he is certainly not justi-fied in expressing positive opinions on the matter. Through-out his work there is no clear distinction between the volun-

tary and involuntary, the cerebral and spinal motions of theextremities, and other parts subject to contraction. A lesspositive dictum would, therefore, have been more commend-able. We venture to say, that any man well studied in nervous

physiology and pathology, on going into Mr. Tamplin’s cases,might clear away many doubts and discrepancies. Operatingempirically, without reference to causes, mistakes must in-

evitably happen, and cases not proper subjects for the knifemust be operated on. Accordingly, we find Mr. Tamplinstating that arteries have been wounded, and required tying,and that abscesses have formed under this empirical system ofmangling the body. Without a reference to principles, theorthopcedic surgeon is merely a mechanist, more able, it istrue, than the old mechanical practitioners, but merelyworking with the knife instead of the bandage and the screw.

It might have been expected that Mr. Tamplin would havelooked a good deal into the nervous system, as lie repudiatesentirely the idea of such a power as muscular irritability.He observes, in a note:-" I have no belief in the inherent irritability’ of muscular

fibre; nor do I consider the contraction of muscle after deathany evidence of such inherent irritability. Doubtless, themuscle is freely supplied with nerves, and those nerves divideand re-divide, and anastomose freely, in every direction; butit is the irritation of these muscular nervous fibres, and thatonly, in my opinion, which occasions the contraction of themuscle. But this is not, to my mind, to be considered asmuscular irritability, but an irritability of the nerves ramifyingin and supplying the muscle; this irritability, as a natural con-sequence, affectwg the muscle itself."-p. 41.

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We do not admire Mr. Tamplin’s physiology. It has thedemerit of being entirely without proof, and we are not awareof any specific labours or experiments which should givehim a right to dogmatize in opposition to the most modernand complete researches into the subject. ,

It could hardly be expected, after this, that Mr. Tamplinwould be happy when he did attempt to elucidate the causesof contraction. We quote the following example :-" Having now pointed out to you the true characters of the

deformities of the foot, I may just draw your attention to thecongenital deformities. These consist of talipes varus, talipesvalgus, and talipes calcaneus. I have never met with talipesequinus. You will recollect I stated, that, in my opinion, itwas position, and position alone, which caused these mal-positions (or rather, the permanent extreme natural position,for this is its real character) during uterine existence; andif you observe the character of these three congenital de-formities, I think you will have little difficulty in reconcilingthe possibility, if not the probability, of this being the case.Take the first-mentioned talipes varus. There are manypositions in which the extremities of the child may be keptin utero, which would adapt it better to the cavity of theuterus, provided the feet were inverted; and it so happens,that by far the greater number of congenital cases consist ofdouble varus; and when it does not consist of double varus,nothing is more easy to account for than one or other ex-tremity being so placed that the foot should grow in thatposition, whilst its fellow may be free and unconfined. Then,if you refer to congenital varus, (query, valgus,) this also maybe easily imagined-that the extremities, or extremity, may beso situated that the flat surface of the feet press more or lesson the walls of the uterus, if not constantly, sufficiently toinfluence the position of them during the growth of the bonesand ligaments."Then, again, take talipes calcaneus : this, also, is a position

that may as easily be imagined to be constantly effected,according to the position in which the extremities lie; and ifthey are so situated, that the anterior portion of the sole ofthe foot presses more or less on the walls of the uterus, ofcourse the flexed position is the one it would assume, and thatwithout any difficulty or resistance; and if we suppose, duringthe motions of the child, the position of the feet may be moreor less altered, as it regards the extreme amount of flexion,yet if, after these active efforts have ceased, the feet re-assumethis position, the gastrocnemius remaining passive, which itwould do, of course the greatest amount of flexion would mosteasily take place, and thus become permanent, the flexorsgrowing in the natural position."-p. 103. t

This, to our mind, is confused and inconclusive. Positionin the foetus is not like position in after-life. It would be an

impeachment of nature to suppose that morphology dependedon mere position. There is every reason for believing thatthe feet can rarely come in lasting contact with the wallsof the uterus. The size of the uterus, and the liquor amnii,tend to prevent this. If pressure or position could be supposedto exert any material influence, we ought to have contractionof the muscles of the neck most frequently, and there oughtto be constantly morbid genuflexion, and contraction of theelbow. But this does not happen. The voluntary move-ments of the body, after birth, soon obviate the stiffnesscaused by intra-uterine position. Other causes than the

merely mechanical must be looked to. The influence of tone,of muscular irritability, of cerebral motor action, of spinalmotor action, must all be studied, with reference to thesedeformities, before a correct pathology, or a scientific practice,can be evolved.As regards operative skill, and the adaptation of mechanical

means to alleviate deformity, Mr. Tamplin may be a goodsurgeon; but his book is not a scientific work, and certainlydoes not advance our knowledge of the subject on which ittreats. Indeed, it indicates that he is a century behind hiscontemporaries in an acquaintance with the physiology andmechanics of muscular action,-the two chief branches ofknowledge involved in discussing with utility the " Natureand Treatment of Deformities."The work is illustrated by numerous woodcuts. In so far

as these exhibit deformities, and illustrate modes of treatment,

(and there are many such in Mr. Tamplin’s work,) they arevaluable; but we are not inclined to be indulgent to thepictorial results of treatment. It would be quite sufficient tosay that benefit was conferred on the patient, or to pro-nounce a case cured, without putting a contracted leg anda well-proportioned one, a wry neck and a handsome face, injuxtaposition; to say, this before the operation, and this, aftertreatment. They look too much like the caligraphic speci-mens of good and bad writing before and after taking lessons.

BRITISH AND AMERICAN MEDICALJOURNALS.

SUGGESTIONS REGARDING THE ANATOMICAL SOURCE AND PATHO-

LOGICAL NATURE OF POST-PARTUM HEMORRHAGE.

IN the Northern Journal of Medicine, we find a communica-tion on this important subject from the pen of PROFESSORSIMPSON. He commences by showing that uterine contractionhas less influence on uterine haemorrhage than is generallysupposed. Thus, in placenta praevia, when the placenta hasbeen removed, and the uterus is still expanded over the child,there is little or no tendency to haemorrhage. Again, itdoes not necessarily occur when the placenta remains in theuterus after the expulsion of the foetus, or during the alternatecontractions and relaxations which are often observed. On

the other hand, haemorrhage sometimes supervenes when theuterus appears contracted and reduced to its ordinary size.Professor Simpson observes-" No doubt the occurrence, after delivery, of great and

decided atony in the whole muscular system of the uterus,does assuredly give rise to post-partum haemorrhage. But ifI may judge from my own observations, I would venture toremark, that the morbid condition which is most frequentlyand earliest seen in connexion with post-partum haemorrhage,and which is specially remarkable in cases where the floodingis more enduring than usual, is a state of irregularity andwant of equability in the contractile action of different partsof the uterus-and, it may be, in different planes of theuterine fibres-as marked by one or more points in the organfeeling hard and contracted, at the same time that other por-tions of the parietes are soft and relaxed-and by the con-tracting and relaxing fibres slowly but frequently changingtheir relative situations."

Hence our object in arresting haemorrhage which is notdependent on a traumatic or organic cause, should be, toendeavour to produce, not merely a certain amount and

degree of uterine contraction, but also a certain equabilityand uniformity. Professor Simpson sums up his views in thefollowing suggestions

" First.—Uterine haemorrhage, after the separation of theplacenta in any of the stages of labour, is not arterial in itscharacter. The utero-placental arteries are numerous, but solong and slender* as to become readily closed; 1, by thetonicity of their coats ; 2, by contraction of the uterinefibres upon the course of these vessels themselves as theypass through and amid the uterine structure ; and, 3, andprincipally, by the changes in their tissues produced by themechanical rupture of their coats,-torn arteries being little,if at all, liable to bleed,-and the placenta being separated bya true process of avulsion.

" Secondly.-Haemorrhage, therefore, under the conditionssupposed, is venous in its source and nature. Further, it isspecially important to mark that it is a venous haemorrhageby retrogression. The forward course of the uterine andutero-placental venous circulation is from the dilated maternalcapillaries or cells of the placenta towards the periphery ofthe uterus, and the ovarian and hypogastric venous trunks.In uterine haemorrhage, the blood that escapes, instead offlowing onwards, regurgitates backwards into the uterinecavity." Thirdly.-The mechanism by which, after the separation

of the placenta, this retrograde course of -the venous circula-

* Professor Simpson refers to the utero-placental arteries seen in WilliamHunter’s beauhful preparations.