had ceased for some time; the bones were supported by a gutta-percha splint moulded to the limb, and he was permitted to leave his bed and on crutches. go about August 10.—Can lean his weight on the limb, union is firm and the splints were removed, the part supported simply by a well-adjusted bandage. From this date he was considered cured; the strength of the limb gradually and steadily increased-the leg now became muscular, and he soon resigned the use of the crutches. The accompanying wood-cut is from a photographe taken seven months after the operation. At that period he could go about the city, and walk a whole day without fatigue. Shortening was very slight—not over one inch and a half-he did not require a high-heeled boot to compensate for what he had lost. I am indebted to Messrs. R. S. Parker, and E. C. Walsh, for the notes of this case. The second case of excision was somewhat different in the origin of the disease, and occurred in a young man of robust appearance, who was admitted into the Montreal General Hospital on 18th May, 1866. The following account is from the notes, kindly furnished me by Mr. J. H. Chipman :—William Davis, aged 22 years, a native of Scotland, tall well-developed and muscular, was admitted into the Hospital under the care of Dr. Fenwick. Present state :-The right knee joint is partially anchylosed, the limb is bent nearly at right-angles, he cannot put his foot to the ground, there is a very limited motion in the joint, the patella is perfectly attached to the femur. At the inner side of the thigh, close to the joint, there exists a sinus, which leads downwards and outwards in the direction of the joint, and, on introducing a probe, the bone is found denuded and bare; there are marks of old cicatrices on either side of the thigh, somewhat above the condyles of the femur. From these, he stated pieces of bone had come away on several occasions. He is of medium height, well built, muscular, dark hair and eyes, is well-nourished, does not suffer any inconvenience from his leg, but, from the circumstance of being informed by his medical attendant that he must lose his leg, and from its uselessness in its present condition, he determined to seek assistance in the hospital in our city. Previous history:—About nine years ago he suffered from rheumatic fever; his right knee joint was first attacked, and the other joints in succession, he was three months under treatment before was able to leave his bed, the disease seemed to locate itself in the right knee joint, which remained stiff, and since that period he has suffered from inflammatory attacks of the joint, coming on at intervals of three or four weeks. Three years ago the joint became very stiff, and openings formed in the neighbourhood, which discharged freely, and several pieces of bone came away, when these sores healed up. Eighteen months since, the leg became fixed in its present semiflexed condition. The man is anxious to have anything done to save his leg. In consultation it was agreed to excise the joint, which was performed on the 21st June, 1866. The U incision was employed, and about two inches of the bones removed. The head of the fibula was found diseased, and had to be removed; considerable oozing followed, but not sufficient to weaken the patient, still a clot formed beneath the flap after the leg was put up. The splint used was a box carefully padded; the wound, after it was brought together with sutures, was simply dressed with cold water and lint. In the evening he did not complain of pain or uneasiness, except in the instep, pulse 116 full, no sickness or vomiting; has taken a little beef tea since the operation, to have 3 j. of Tinc. opium, to induce sleep. June 22. Slept very little; the pain in the instep is rather severe, no undue pressure appears to exist, the wound looks well, and a slight bloody discharge coming away, pulse full 102, countenance flushed, tongue foul, does not care for food, but has taken a little beef tea; a hypodermic injection of morphia to be administered at bed-time. June 23.-Slept well last night, and expressed himself as much refreshed; still some pain in the instep; a desk was made to rest the splint on, and elevate the foot, which position gave him much comfort. He was rather feverish, and complained of thirst, pulse 112 full. The following prescription was ordered :- June 24.--Feels very little pain in the leg, no starting, complains of pain in the back, from difficulty of obtaining a comfortable position, bowels not moved, pulse 98, tongue still foul, takes more nourishment. June 26.-Pain in the back nearly gone, he had a pillow placed beneath the loins, which gave him great comfort; discharge from knee is becoming more copious, consisting of blood and pus; several masses of the old clot were pressed out, feels comfortable, and takes as much nourishment as usual since the operation. June 29. Since last report has gone on favorably; the discharge is becoming more healthy in appearance, bowels not opened since the operation; to have castor oil, slept very well, ligatures, of which there were five, all on small vessels, came away; takes abundantly of beef tea and chicken broth. The bones had become somewhat displaced, and were readjusted. July 3.-The next report is under this date. He is going on most favorably, sleeps well, bowels acting every second day, he takes the full diet of the hospital, and a pint of beer; the wound nearly healed, four sutures removed, the discharge, which is moderate, is of healthy pus. July 16.--All the sutures taken out; on careful examination, the bones were found somewhat displaced, the femur being to the outer side, and tibia internally; they had to be readjusted, which is to be regretted, as considerable union had taken place; the discharge has altered much in appearance, resembling synovial fluid. July 28.-Discharge not very great, he is continuing on as well as can be expected; eats well, sleeps well, and has no pain; is very anxious to leave his bed. On the 9th August all discharge had ceased, and on taking the limb down a day or two subsequently, the union was found perfectly strong. There will be shortening of about two inches. The man may be considered cured, although I do not consider it advisible to remove the splints for a week or two. REVIEWS AND NOTICES OF BOOKS. A Treatise on the Principles and Practice of Medicine, designed for the use of Practitioners and Students of Medicine. By AUSTIN FLINT, M.D., Professor of the Principles and Practice of Medicine in the Belvue Hospital Medical College, and in the Long Island College Hospital, &c., &c. Philadelphia: Henry C. Lea, 1866. Montreal: Dawson Brothers. THE reputation which Professor Flint enjoys as a teacher of the practice of medicine in the United States, has led us to examine the above work from his pen, with all the care that a limited time would allow; and, while we find much, very much, to commend, we cannot help thinking that his style has too much of terseness to make it pleasant reading, to devote more than an hour or two to its persual, and that perhaps he is somewhat too dogmatic in stating the treatment to be followed in certain affections. In a measure, he may be styled "conservative" in his doctrine, and we imagine it would not give him a pang of regret if he could never lay his hands upon a lancet, to employ it in depletion, or never be able to make use of calomel or antimony in the treatment of inflammatory affections. In this matter, we think, he has gone a little too far, and has given the anti-mercurialists strong peg upon which they can hang their chronic grievances of the evils attending the use-mind not the abuse-of mercury. Upon the vis medicatrix naturæ, Dr. Flint seems to have much faith—and that it is a power that works at times wonders, we will not for a moment deny—yet it would be a doctrine at once pernicious and disastrous, to instil into the mind of the young practitioner to depend too entirely upon the conservative power of nature; and much of Dr. Flint's writings seems to point to that method of treatment. It is a well known fact, that many physicians believe that diseases havechanged their type within the last twenty-five years; among those who hold that opinion is Professor Stokes of Dublin. In speaking of the treatment of acute pleurisy, Professor Flint thus incidentally alludes to this question: "The opinions held by some, that diseases, and the human constitution have undergone a notable change during the last quarter of a century, and that blood-letting and other anti-phlogistic measures are less appropriate now than formerly on this account. This opinion seems to me not well founded, after a professional experience, extending beyond the period named. I do not hesitate to express a conviction that acute inflammations at the present day are essentially the same as they were twenty-five years ago, and that antiphlogistic measures were no more appropriate then than now. Were it true that such changes have occurred, the fact would strike at the root of medical experience. If changes requiring a revolution in therapeutics are liable to occur with each successive generation, it is evident there can be no such thing as permanent principles of practice in medicine; the fruits of experience in our day, which so many are striving to develope, will be of no utility to those who are to come after us." Upon a question of such importance as this, we think the author has been somewhat unnecessarily brief. It would have satisfied us more had he stated his reasons a little more in detail, for coming to such a conclusion. We do not contradict the opinion he has expressed, for we candidly admit the subject is one involved in a good deal of mystery to us, yet we think had he entered more fully into the reasons, gathered from his long experience, which have led him to this conclusion, he might have exercised considerable weight in influencing minds not biased to either doctrine yet, and with whom his somewhat abrupt dogmatic assertion will have little weight. For instance, Stokes, reasoning for the opposite side, has told us that in certain years, fever raging in Ireland had certain well-marked symptoms, which he described at much length, and he then gradually traces the change in the type, which seems to him to have taken place. We deeply regret that Dr. Flint has not thus fully entered into the opposite side of the question, which is the one he holds. In the treatment of pleurisy, he says:-" The regulation of the amount of drink ingested is an important point with reference to the promotion of absorption. The elimination of water by the bowels or kidneys is of little avail, if the patient be allowed to take fluids into the system abundantly. The quantity of fluid ingested should be as small as is compatible with comfort. The treatment is often rendered inefficient by inattention to this point." Pneunomia is styled pneumonitis; also, pleurisy-pleuritis. We confess a dislike to these names, and have always rebelled against calling them by such terms, preferring the well-known pneumonia and pleurisy. There is a tendency, now-a-days, and a very pernicious one it is, to multiply and alter terms which only tends to mystify and perplex; we can conceive of no good to come from it. Speaking of pneunomia, and alluding to the absence of the chlorides from the urine, which is, however, not peculiar to this disease, he says:-"It is stated that the chlorides are found in abundance in the matter expectorated, during the time of their disappearance from the urine." In describing the treatment, he thus alludes to the alcoholic portion of it; and now that a new school, under the direction of Professor Gairdner, of Glasgow, is springing up, who deny the ultility of alcoholic stimulation in this, and all other diseases, it is important to have the opinion of such an able authority as Dr. Flint. He says, at page 167: "Alcoholic stimulants form a very important part of the supporting treatment in this disease, as in all other disease wherever the great object is to keep the patient alive until the disease has reached the end of its career, and advanced into the stage of resolution. The principle is the same as in essential fevers. And here, as in the management of essential fevers, alcoholic stimulants are indicated to an extent commensurate with the danger from failure of the vital powers. In certain cases of pneumonitis as in typhus, and typhoid fever, and other affections, there is often a remarkable tolerance of alcohol, and the only guide, as regards quantity, is the effect as manifested by the symptoms. No abstract rules can be laid down but careful observation must furnish the rule proper for each individual * If pushed to an injudicious extreme they are as potent for evil, as they are potent for good when judiciously used. * They are always indicated as soon as evidence appears of any tendency to failure of vital powers, and of this the action of the heart, represented by the pulse, is the best criterion. Feebleness, great frequency, and pulse vibratory or thrilling, but compresible, denoting case. * * * * |