phenomena which attend it, depending on a high degree of vigour in the vascular system; the absence of this power in the vascular system in childhood accounts for the absence of the symptoms which characterizes pyrexia. That very tendency to venous congestion, which is so strikingly marked in childhood, increases the excitability of the nervous system, and produces a liability to convulsive affections. Of the truth of this statement the numerous hypochondriacal and hysterical affections that occur in the adult are ample evidence, as are the cramps and spasmodic pains which attend deranged menstruation and hemorrhoidal affections.

Now it is very probable that there may be in the remarks just quoted rather more of the transcendentalism of the Vienna School than will suit all our readers. Truth, however, forms the basis of Dr. Mauthner's remarks, and perhaps we should not find it easy to express his meaning better. He next glances at the different organs whose disorders are often attended with convulsions, among which the brain and its diseases hold the foremost place. He notices the frequent occurrence of convulsions as the fatal termination of various affections draws nigh, when they indicate that death has begun to assail the centres of life. His next remark is one that we have not seen before in print, but we can confirm it from our own observation, except that we do not think the cessation of thoracic symptoms is quite so complete as he here represents it.

"I have," says he, "often observed in cases of extensive hepatization or tuberculization of the lungs, during the course of which the brain was perfectly unaffected, that the children a few days before death lost all chest symptoms, that the cough and orthopnea seemed to have entirely vanished, their appetite returned, and they seemed cheerful, when convulsions suddenly came on, followed in a few hours by death." (p 362.)

Equally correct is the following statement:

"Another tolerably frequent phenomenon is this, that in those cases of cerebral disease which were marked at their commencement and during their course by violent convulsions, the act of dying is generally quite tranquil, owing to the paralysis of the brain having suspended its influence over the muscular system." (p. 363.)

Before he passes to the consideration of the treatment, he introduces one very important caution, which we must extract:

"Inasmuch as convulsions are a frequent attendant on disease of the brain, it is certainly very natural to turn one's attention first to the nervous centre. It often happens, however, if much care be not taken to investigate a case thoroughly, that leeches and cold applications to the head are hastily ordered, and calomel given; when the presence of pneumonia is afterwards detected, or some cause of gastric disturbance found to exist, without due attention to which no permanent amendment can result from any treatment. Inflammations of the chest are particularly apt to lead into this kind of error. Their real symptoms are masked by convulsive seizures, the medical attendant fancies on the first day that the case is one of inflammation of the brain, on the next day he thinks it must be pneumonia, and thus the uncertain diagnosis leads to vacillating treatment, and inuch mischief is the result." (p. 364.)

We do not enter into any minute account of the treatment suggested by Dr. Mauthner in the different forms of convulsive attacks. The judicious employment of known remedies, not the eager hunting after new medicines,

has long been the characteristic of the sound physician. The cases appended to this chapter afford the best possible illustration of the various forms which these affections assume, and the various treatments they require.

The last eighty pages contain an account of diseases of the spinal cord in children. They contain much that is deserving of notice, but we have already exceeded our limits, and must take leave of Dr. Mauthner, heartily recommending his book as the most valuable contribution to practical medicine which has appeared for many years from the Vienna school.

ART. VI.

Die angeborne Verrenkungen. Mit zwei Tafeln. Von LUDWIG JOSEPH MELICHER, Doctor der Medicin und Chirurgie, &c. &c.-Wien, 1845. Congenital Luxations. With two Plates. By LUDWIG J. MELICHER.— Vienna, 1845. 8vo, pp. 220.

LUXATIONS of the different articulations of the body appearing at birth is a subject which, till within the last few years, has but little occupied the serious attention of the profession either at home or abroad, and the work before us is, we believe, the first monograph on the topic which has been offered to the public. The theme we need scarcely say is far from exhausted, and yet a great store of facts has been accumulated with which it behoves every well-informed medical man to be acquainted. With the execution of the treatise before us we confess we have been disappointed. It is divided into two sections: the former occupied with what the French call generalities; the latter with details; and yet from want of due elaboration,-not to say more-there is a lack of distinctness, and an amount of repetition, which is vexatious. The subject however being handled ex expresso, and didactically, proves decidedly suggestive; and though we may not closely follow the plan of the author, we shall endeavour to condense the information he communicates, and add such elucidations from other quarters as suggest themselves.

And let it not be supposed that this is a subject which is more calculated to excite curiosity than to instruct the practitioner. Far from it. Cases are neither of rare occurrence, nor of trifling moment.

"The frequency of these luxations," says M. Melicher, of one variety only, "is greater than is generally supposed. Since the year 1826 when Baron Dupuytren first directed attention to the subject, 180 cases, in various joints, have been recorded. In the course of 18 years this eminent surgeon had seen 26 cases, and M. Guerin had met with 30. Heine had witnessed 11 cases of congenital luxation of the femur, Chelius 9, and I have seen 6. Mr. Smith of Dublin records 5 cases in the shoulder-joint, Adams and Cruveilhier have seen it in the elbowjoint, whilst various authors have noticed luxations of other joints, as will be stated in the sequel."

And as to its importance,

"I have known," said Dupuytren, "many individuals affected with original luxation, by sheer mistake of diagnosis, confined to bed for years! I have known others subjected to remedies without number,-to blistering, leeching, cauteries, moxas, &c. &c. I remember one poor girl, who had moxas applied no fewer than twenty-one times, without the useless and barbarous treatment, of course, producing the slightest benefit."

Nurses, again, are in this way often subjected to great injustice, and are most unworthily accused, by heart-broken parents, of having carelessly, it may be barbarously, lamed their children for life; annoyances, these, which competent knowledge and intelligence of the medical attendant would at once have anticipated or removed. Although for ages the subject has been involved in obscurity, it has recently, by the rapid advance of science, been greatly illustrated; and though much yet remains to be done, an account may be supplied not devoid of interest, and which may enable the practitioner to encounter and dispose of the cases he meets, with comfort to himself, and satisfaction to his patient.

Observation and experience have confirmed, what a moment's reflection would suggest to every intelligent practitioner, namely, that luxations appearing at birth, may arise from various and different causes. 1. Considering the nature of the process of parturition, no one can be surprised that the several forces which are then applied to the infant coming into the world, should in some instances lead to dislocation of one or more joints. True, the injury to the limb may not always be of the nature of a luxation, but frequently it is so. These kinds of cases it is evident, though occurring at birth, are not entitled to rank properly as congenital luxations. Hence they should receive a preliminary consideration, because as bearing on diagnosis and practice, they must not be overlooked. They belong to the section of the acquired and violent luxations of our author, Luxationes acquisitæ violentæ. As produced during the process of parturition they may appropriately be designated as obstetric luxations, L. obstetrica.

The remaining species as often, at all events, occurring during fœtal life, may well be classed under the category of congenital, Luxationes connatæ vel congenita. They are very different however in their origin and early history. 2. The joints in the foetus are, more or less, liable to those complaints which occur in these parts in after life. Of these diseases three have been specified as frequently producing dislocation; namely, first, morbus coxarius, or coxalgia; secondly, hydrathosis, or an increased secretion and accumulation of the synovial fluid; and thirdly, a hypertrophy of the vascular and fatty cellular structure, which has been named the Haversian gland, which mechanically may dislodge the head of the bone from its socket. Diseases of this character may occur in several joints, though they certainly have been noticed more frequently in the hip joint than in the others. These together go to form that species of disorder which has been denominated spontaneous luxation, L. spontanea, consecutiva. 3. It would appear that frequently the immediate dynamic cause of the disorder is an irregular action of the muscular apparatus, excited by a derangement in the nervous system, the true efficient cause,- -a species this which may conveniently be designated functional luxation, L. functionalis. 4. And fourthly, one of the most aggravated, if not the most common species of this affection, is a complaint which has its origin, not so much from a morbid, as from a defective action. It appears to arise from what, in general terms, may be denominated arrested development of the joints, wherein the beautiful apparatus of these parts is more or less defective and incomplete; the consequences of which will at once be evident. This species constitutes the L. originalis, the L. originelle, and congenital malformation of Dupuytren. All these species, moreover, may

and do occur in very different degrees; and hence there are specimens of complete and incomplete luxation. Under the head then of obstetric luxation, spontaneous, functional, and original, we shall arrange such remarks as our space allows. The two former need not occupy us long.

1. OBSTETRICAL LUXATION. We commence with the obstetric variety of luxation as the simplest, and probably the most familiar of all. And here, in reference to those not unfrequent blunders to which we have adverted as described by Dupuytren, we may allude to a rule, applicable to all the species, noticed by our author as observed in the great Maternity Hospital at Vienna; according to which the child, when undergoing its first ablution, is minutely examined by the nurse who performs the duty, with the special view of ascertaining that nothing abnormal appears in any part of the frame. If anything of the kind is discovered, it is noted at the time, and all becoming attention is subsequently bestowed upon it. The localities, according to M. Melicher, in which luxation from violence may occur, are to be found in every free joint of the body; but they are principally observed at the shoulder, elbow, ribs, hip, and ankle.

With the view of throwing light on the liability of the different joints to luxation, and the causes and circumstances in which it is most apt to occur, the author made numerous experiments on the dead subject with the object of inducing artificial dislocation, and this where opportunity offered, where the child was in utero, as well as out of it.

Accordingly he experimented upon the bodies of children, respectively of the ages of seven, eight, and nine months, and found that the disposition to luxation in them depended upon the incomplete condition of the surfaces of the joints. At the earlier of these periods of fœtal life, the free (arthrodial) joints are barely indicated, and in the latter months there is nothing more than a superficial excavation. In the humerus, for example, there is a wide disproportion between the size of the head of the bone, and the cavity in which it lodges. Besides the condition of the bones and cartilages, the natural laxity of the other component parts of the joints, of the ligaments, tendons, and muscles, may all be regarded as predisposing causes of the accident.

The author instituted another series of experiments upon children who had arrived at the full time; in relation both to the humerus and the femur. He found luxation of the humerus could be most easily accomplished towards the anterior edge of the scapula; and to be more difficult in the directions inwards and forwards into the subscapular fossa, and outwards and backwards into the fossa infraspinata.

Again, as regards the hip-joint, he found that luxations upwards and outwards are the most difficult to superinduce. He succeeded only in two cases out of thirty, in which he attempted to produce this luxation,—the epiphyses in many cases giving way. In this joint the luxation downwards and backwards into the ischiatic notch is most readily effected, though even this is no easy task. M. Melicher never succeeded in producing dislocation downwards and inwards into the foramen ovale, or upwards and forwards upon the pubis. From these experiments, the author believes that, in violent luxations, and probably in others, the head of the femur usually leaves the acetabulum at its anterior and inner edge, and is placed between this spot and the ischium, and then slides backwards; so

that luxations during foetal life, do not take place downwards and backwards into the ischiatic notch, but occur upon its outer edge, and thus the head is either by degrees, or suddenly, shifted from the external edge of the acetabulum by a second dislocation upwards and outwards, into the fossa iliaca externa, and there becomes fixed; an effect which is produced by the position of the extremities of the fœtus in utero; and from their movements, by the contraction of the muscles, especially of the glutei moving the head of the bone upon the external edge of the acetabulum.

But we shall not dwell longer on these details; and may here, in a few words, dismiss the obstetric variety of luxation, which, as we have said, does not accurately belong to the subject of congenital dislocations. The causes most likely to operate, enumerated by our author, are irregular and unwonted contraction of the uterus; irregular and unwonted position of the child, more especially of one or other of its extremities, faulty contractions of the maternal pelvis, from mollities ossium, &c. &c. Capuron believes that it may occur in cross births, from the traction used in the inguinal region, by the fingers. Upon six trials of this kind of delivery, effected upon women who had died undelivered, the child being also dead, M. Melicher found that luxation was produced twice, each in one side of the pelvis. This, however, was effected not by the finger but by the crotchet.

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The diagnosis in this variety of luxation cannot with an average share of attention be very difficult. A degree of external injury must necessarily exhibit itself, if not at the moment, yet within a few hours of the child's birth, the soft parts being implicated not less than the articulation. In fact, however, though there may be present both the external marks of violence, and the symptoms of deeper-seated injury, it will still remain to be ascertained whether the mischief arises from dislocation, or from fracture. This latter accident, it would appear, from M. Melicher's experiments, is the more likely of the two, and will require to be treated upon the common principles for such cases. Respecting cases of luxation, artificially induced, M. Melicher observes, once dislocated, the head of the bone remained out and was replaced only with the greatest difficulty." In eighteen such cases he only succeeded in effecting reduction three times; once at the shoulder, and twice at the hip. He contends, that the task will prove still more difficult in the living subject, but this seems more than doubtful; and we question indeed, whether such experiments elucidate the subject. Could the parts once be replaced, which, with sufficient care, should certainly be accomplished, the natural action of the muscles and elasticity of the surrounding parts, would greatly contribute to keep all right. The prognosis in this variety and the treatment must evidently be regulated by the common rules of surgery, and without doubt with a fair prospect of success.

II. SPONTANEOUS LUXATION. Nor need the species of spontaneous luxation occupy us long. Every day's experience is teaching that many of those diseases we are familiar with in the adult, are apt to show themselves in the foetus; and the modifications they thus undergo though curious, are such as the first principles of the science would lead us to anticipate. Diseases of the joints form no exception to this remark, and