690

ternal to the tendon of the extensor longus digitorum, obliquelydownwards and outwards to just below and in front of theexternal malleolus ; through this was protruding the head andneck of the astragalus. This bone was, therefore, robated on avertical axis drawn through the centre of the bone, so thatthe semilunar facet for the internal malleolus was directedforwards and the triangular facet for the external malleolusbackwards, and the long axis of the superior saddle-shapedarticular surface was directed from before backwards,instead of in a transverse direction. The bone was held inthis position by a pazt of the external lateral ligament anda band of fibrous tissue on the inner side of the bone.These were divided, and then the bone was easily with-drawn with the fingers. The astragalus was intact withthe exception of a slight graze on the head of the bone.There was no fracture of any other bone, and but slightbruising of the soft parts. The cavity left by the removalof 1 he bone was thoroughly irrigated with a solution of cor-rosive sublimate, a drainage- tube inserted, and the woundclosed and dressed with double cyanide gauze. The limbwas placed on a back splint with a foot piece. The subse-quent progress of the case requires no comment. Therewas a little quiet suppuration, which somewhat retardedrecovery, but otherwise he went on well, and was eventuallydischarged with a sound and useful limb.

DEVONSHIRE HOSPITAL, BUXTON.FRACTURE OF THE ANTERIOR INFERIOR SPINE OF THE

ILIUM BY MUSCULAR ACTION.

(Under the care of Mr. SHIPTON.)THE case which Mr. Gibson (to whom we are indebted

for the notes of the case) describes is a most unusual one,and our works on surgery, general or special, contain noreferences to such an injary. Fracture of the anterior

superior spine as a consequence of direct injury is not un-common in our accident wards; and there are at leastfive recorded examples of separation of that process bymuscular action. Fracture involving the anterior inferiorspine, except as the consequence of gunshot injury or asevere crush of the ilium, is apparently unknown.E. M-, aged thirty-five, bricklayer’s labourer, was

admitted into this hospital on Dec. 12bh, having fallenfrom a scaffold sixty feet high. He was found to be in asemi-conscious condition. The right leg was more evertedthan the left one, the front part of the right thigh had lostits rounded outline and was a good deal flatter than theother. There was no fracture of any limb. A catheter waspassed without difficulty and four ounces of clear urinedrawn off. On grasping the ilia, no mobility or crepituscould be made out. On carefully examining the pelvis, apiece of the anterior edge of the right ilium, about one inchin length and three-quarters of an inch in breadth, com-prising the anterior inferior spine with the origin of theshort bead of the rectus, was found to be detached from theilium to the extent of about a quarter of an inch, and couldbe easily moved between the fingers. There was no rednessor ecchymosis on the skin over the part, but a slightdiscolouration appeared three days later simultaneouslywith very marked ecchymosis around both eyes. Therectus was relaxed, and later on, when the patient hadrecovered consciousness, he was asked to flex the right thigh,which he did with difficulty and pain-situated au the seatof fracture,-bub only raising the thigh a few inches fromthe b; d ; and the anterior inferior spine was found to bestill further separated from the rest of the bone. No otherinjury was found. On obtaining the history of the accidentfrom the patient, it was ascertained that whilst canying ahod full of bricks over his left shoulder his foot slipped,and to prevent the bricks falling on him hA threw the hodbackwards, falling on " all-fours " into a quantity of softshs,le, sixty feet below. This statement was corroboratedby a fellow-workman who saw the accident. The patientmade an uninterrupted recovery, a good deal of callus beingthrown out around the fracture.Remarks by Mr. Grssorl.-The case is of interest, as the

fracture appears to have been caused by muscular action. Ihave come to this conclusion on consideration of the follow-ing facts : (1) The history of the case shows that the rightrectus must have been suddenly and forcibly brought into

action when the patient threw the hod over his leftshoulder, so as to help to steady the pelvis, and so preventhim fiom falling backwards. The long head of the rectuswas probably ruptured simultaneously. He fell on hishands and knees into a quantity of soft shale, which par.tially buried him, and therefore ih is improbable that theinjury was caused by the fall. 2. The absence of redness.,or bruising until the third day, when a little discolourationappeared over the part simultaneously with considerableecchymosis around both eyes. 3. The anterior inferior spineis well protected from direct violence on all sides by muscle,and on the outer side, where it is most accessible to injury,.it is shielded by the great trochanter as well. 4. Absenceof evidence of any further fracture of the pelvis. Havingnever heard of a similar fracture by muscular action Eventure to record the case.

Medical Societies.

ROYAL MEDICAL & CHIRURGICAL SOCIETY.

Operative Treatment of Congenital Dislocation of the Hip.AN ordinary meeting was held on March 22nd, the Pre-

sident, Mr. Timothy Holmes, in the chair.Mr. BARWELL communicated a paper on the Operative

Treatment of Congenital Dislocation of the Hip. Thecondition thus called was, as many anatomical investiga-tions had shown, absence, more or less complete, of theacetabulum, usually combined with a certain truncation ofthe head of the femur. The well-known signs of the de-formity were merely mentioned, and a symptom not hithertonoticed was described and illustrated by a sketch rapidlytaken from a patient-namely, when she bowed forwardswith straight knees till the back of the pelvis was nearlyhorizontal the great trochanters, or the trochanter iuunilateral cases, projected upwards and outwards from theossa innominata, and lay in some cases actually higher thanthose bones. Stress also was laid on a jolt which occurredwhen the limb was drawn down far enough to Ining thehead of the bone into its normal situation. Two prevalentmethods of treatment were described : the one by divisionof the rotators and capsular muscles, originating withM. Guerin, and recommended by Mr. Brodhurst ; the otherby long-continued recumbency with extension, inauguratedby M. Pravaz, followed in America by Dr. BuckminsterBrown, and in England by Mr. Adams. According to thelast-named the recumbency must occupy two or two yearsand a half, and be followed by a year and a half of instru-mental treatment and cf go-cart and crutches. Io must,begin, in order to have chance of success, in infancy, or,ery little beyond that period. The writer stated that thi&deterrent period of treatment might be very much shortened,the chances of success greatly increased, and cases seen at a,later age might be cured by the division of certain muscles.But he contended that the rotator and capsular muscles were,valuable aids in keeping the head of the femur in situ, andmust be left intact; while the muscles which ran from thepelvis to the femur, in a direction almost parallel to theaxis of the latter bone, being those which, in the absence of’an acetabulum, propelled its head upward on to the dorsumilii, were those which should be divided. Indeed, theextension which Pravaz and his followers carried out forsuch lengthened periods could only avail by counteractingthis action of those muscles, which might be much moresurely, rapidly, and as safely overcome by division. Threecases were given, the oldest beginning treatment ateleven years of age, in which the author divided theadductors &c., and allowed the patients to get up in afew weekp, and which were completely successful. Aletter from the first patient was given, describing heractivity and power. The author showed one of theyounger patients.Mr. BRODHURST said that in one of the cases, though

the result seemed to be exceptionally good, yet thereappeared to be some doubt whether it had ever been one ofcongenital dislocation ; the femur also in that instance wasshort, and he did not remember ever to have seen a

shortened femur in association with this malady. Theauthor had made a mistake with regard to Guérin’s opera-

691

tion ; the latter only divided the tensor vagina femoris,the gluteus medins, and the anterior part ot the gluteusmaximus ; a weight of five kilogxammes had then beenattached to keep the bone in position. In )865 he operatedon a case of one-sided congenital dislocation of the femur.He divided the gluteus medius, the trocbanteric attachmentof the gluteus mximus, the psoas and iliacus, the gemelli,and the obturators ; be then drew the bone down, andfound that it remained in that position. I was then fixedon a splint for two months, after which all the movements

of the limb could be effected perfectly. At the end oftwelve months no apparatus was used, and there was nodeformity at all. In other cases, where the age was moreadvanced, he had divided the abductor longus, but he hadnever resorted to division of the rectus femoris.Mr. NOBLE SMITH had treated these cases at firsh with a

raised stue, and with this in many the deformity had not,increased, though in some this had taken place. The casestreated by Pravaz’s method had given interesting results,

. but) it necessitated very prolonged rest and expensiveinstruments. In one case in which he had adopted the resttreatment without the instruments he got a good result.He preferred to apply a Liston’s long splint with a perinealband, which was better than extension by weights, for thelabter continued to pull down the limb beyond what mightbe required. He would advocate the treatment by pro-longed rest in all cases except those in which there was- contracture of the muscle".

Mr. MUIRHEAD LITTLE referred to a cape under his carein which the patient was reclining on a long couch withcord extension. After a few weeks there was no difficultyin overcoming muscular action and keeping the trocbanters

. in position. After nine months of this treatment it wasfound that the trochanters remained in position when theweights were removed, and be hoped for a good result.Mr. GODLEE thought that in such a debate a word should

be said regarding Professor K6,iig’s operation of manu-’facturing a new acetabulum. He made a curved incisionabove the trochanter, and then with a chisel reflected a

portion of the ilium downwards towards the capsule. Oneof the cases he had so treated died of diphtheria, and befound at the necropsy, performed some time later, that avery good acetabulum had been formed.Mr. BARKER inquired what occurred to the dorsum ilii

when the femur had been held in position against it for,some time. He doubted if a proper acetabulum could beformed in the absence of irritation or movement.Mr. BOWLBY asked if it were considered that this opera-

tion wa,s necessary in all cases, many of which differed somuch from each other. In some, where the head of thebone was forward, the patients walked well, but where thebone was displaced backwards there was more limping and.greater sliding of the bone on the dorsum ilii. At a timewhen a child began to walk it was necessarily unstable inits gait, but later it had educated its muscles, and thesefacts should be taken into consideration in j judging of the.results of treatment at this early age. In the two youngercases that Mr. Barwell had operated on the procedure had’been carried out at such an early age that it was quiteimpossible to guess what would have happened if they hadbeen left alone.Mr. HOLMES remembered the case which Mr. Brodhurst

had related. The division of muscles which had been re-commended was put forward as accessory to other treat-ment, with a view to hasten it, and he supported the viewthat a judicious subcutaneous section of muscles broughtabout a more rapid result than could be obtained by restalone. Mr. Birwell, in addition, attempted to producesomething in the way of an acetabulum after the mannerof Konig. In spite of Mr. B )wlby’a criticism, he held thatin the greater number of cases of congenital dislocation thedeformity might go on increasing until the patient couldscarcely walk at all, and for these operation was advan-tageous. He added that a valuable appendix to the paperwould be drawings or photographs of the cases beforeoperation was undertaken.Mr. BARWELL, in reply, said that the only object of his

method was to expedite treatment, which was otten other-wise most irksome. He had endeavoured to make a lip ofbone above the femur to form some sort of resistance to theupward gliding of that bone. Many of these cases werenot so easily treated aq some of his critics seemed to thinkHe had not practised Konig’s operation, which he consideredto be too severe a measure. His first case was eleven years

and a half old when he operated. He was not convinced ofthe advantage of dividing the anterior fibres of the gluteusmaximus and the obturatorq.

CLINICAL SOCIETY OF LONDON.

Nerve grafting.-Abdominal Section in cases of RupturedSpleen and Liver -.Mediastinal and Pulmonary Car.cinoma associated with Retraction of Chest Wall-Modes in which a Strangulated Loop of Bowel reactsto the Constricting Medium.AN ordinary meeting of this Societywasheld onMarchllth,

the l’reaidenr, Sir Dyce Duckworth, in the chair.Mr. DAMER HARRISSON read a paper on a case of Nerve-

grafting. After recalling the excellent results which fol-lowed close apposition of the ends of divided nerves theauthor observed that the only satisfactory method of dealingwith nerves the ends of which were too far apart to admitof their being sutured was by nerve-grafting. He referredin detail to the history of eight cases in which this opera-tion had been performed at home and abroad, and thenproceeded to narrate the following case under his ownobservation. A lad. agfd thirteen, was admitted into theLiverpool Northern Hospital on June 4th, 1891, with thefollowing history :-Eleven weeks before a glass cut of thefront of the right wrist divided inter alia the median nerveand all the flexor tendons except the flexor carpi ulnaris. Onadmission the fingers were found to be immovably fixed in theflexed position, paralysis of both motion and sensation beingcomplete, correspondingtothemedian nerve. Trophic changeswere also present, the hand being blue and cold, the skin glossy,and the short muscles of the thumb much atrophied. Mr.Harrisson explored the site of the original injury and foundthe flexor tendons matted together and nearly two inches ofthe nerve had been destroyed, leaving a gap between the ends.Aflier dealing with the tendons the nerve ends werefreshened,thus increasing the separation to two inches, and a grafttwo inches and a quarter in length, taken from the sciaticnerve of a recently killed kitten, was fixed in a positionby one fine catgut suture, at each end passing through thesubstance of the nerve. The limb was then put in a splint,with the hand flexed and the fingers straight. The woundhealed by first intention. Sensibility began to return inthe palm of the hand and over the first phalanx of thethumb at the end of forty-eight hours, and by the thirdday had extended to the first phalanges of the index andmiddle fingers and the terminal phalanx of the thumb, andeventually over the middle phalanges of the index andmiddle fingers. Sensation had not returned in the tips ofthe fingers. There was also transferenca of sensation,impressions from the first phalanx of the index finger beingreferred to the corresponding area of the middle finger.At the end of three months the nutrition of the bandalso showed great improvement. Motion showed no signs ofreturning until the end of five months, when slaghb voluntarymovement was observed in the short muscles of the thumb.Though still feeble, these movements were improving, and.within the last three months the patient had been enabledto oppose the thumb to the index finger. The flexion of thefingers upon the palm was not perfect, doubtless on account ofthe destruction of the tendon of the flexor sublimis digitorum.In another case of the same kind an operation had still morerecently been performed by Mr. Mitchell Banks of Liver-pool upon the ulnar nerve at the elbow after exciion of aneurornatous tumour, four inches being grafted from thesciatic nerve of a dog. Sensation was stated by the patientto have returned within thirty-six hours. Of the tencases quoted by him three had been perfectly successful,six partially successful, only one proving a failure. Heattributed the difference in the success attendingprimary and secondary grafting to the trophic disturb-ances which were present when grafting was resorted toas a secondary operation. Restoration of function tookplace readily enough after long periods of time in respectof sensory nerves, but the degeneration which took placeforthwith in the distal portion of motor nerves renderedrepair slow and the return of function very gradual.-The PRESIDENT asked the author if he could state whatkind of graft formed the best material for a conductingmediam.—Dr. SAVILL inquired what limit could be leftbetween the divided ends of a nerve so that it could under-take its own repair without recourse to the introduction of