- Email: [email protected]
ON EXCISION OF THE HEAD OF THE FEMUR IN CARIES OF THE HIP-JOINT.
361 different meaning to that intended. My object and intention ON EXCISION OF THE HEAD OF THE FEMUR was, the enunciation of the fact, that a very large proportion IN CARIES OF THE HIP-JOINT. of these cases terminate fatally with regard to the child. I must here remind your correspondent that my remark did BY HENRY SMITH, ESQ., M.R.C.S.E., not apply solely to breech presentations per· se, but included LATE HOUSE-SURGEON TO KING’S COLLEGE HOSPITAL. all cases requiring artificial assistance, where it becomes necessary to deliver by the feet. If he examines carefully in Surgery: Excisions of the Ends of Bones, by the statistics of midwifery, he will there discover that my .1Ilodern " S’urgeons A pplicabihty of Resection to the Hip-joint: incontrovertible the is facts; indeed, opinion supported by Operation by Mr. White; by Mr. Hewson; by .1Jfr. Ferguss01’: axiom in dispute seems to have been so generally received, Circumstances to be considered by the Surgeon before Ope2-ating: that most writers on the subject have considered it worthy off of Hip Disease: Foreign Substances to be removed Pathology words are remark. Burns’ first these,-" Breech presentafr01n the Body; Diseased Bone a Foreign Substance: Steps qf tions are more hazardous to the child than when the head1 the Operation for removing the Head of the Femur: 1’reatpresents naturally; for the cord is apt to be compressed when1 ment of the Cotyloid Cavity when Diseased: Subsequent Treatthe head is passing through the cavity of the pelvis." ment. For a further corroboration of my opinion, I beg to refer him also to the writings of obstetricians, from the days ofF AMONGST the many great improvements which have of late Lamotte to the present period; to the experience of practicall years been introduced into the practice of surgery, and which men; to the last number of your journal, where he will findl have in a great degree emanated from the observation and two cases of placenta prsevia recorded by Mr. E. Y. Steele, of7 experience of our own countrymen, none have a higher place Abergavenny, where turning was resorted to, and both: than those connected with operations on bones, and the exchildren were born dead; and lastly, let me direct his atten- cision of joints. Until within a few years, it had always been tion more particularly to the statistics furnished by Dr. customary for the surgeon, when he had to deal with a disease Churchill, in a recent work published by that author. Sta- in a limb which he found he could not cure without an operatistical facts are ugly things in argument; they impede the tion, especially if the disease were situated in the shaft of the progress of all those who are disposed to rest satisfied with bone, or in the principal joint of a limb, to remove the greater broad assertion, or wild and extravagant inferences. For the part or the whole of the limb by amputation. Both patient benefit and satisfaction of those to whom my appeal was and surgeon were satisfied if the diseased part were removed, made, I beg to give the result of the doctor’s investigation:- and life saved, and in order to effect these ends the sacrifice of "First, with respect to frequency, examples taken from an entire limb was considered to be both justifiable and necesBritish, French, and German authorities, gave one in fifty- sary. Thus, for instance, if the elbow-joint happened to be three cases and one-third. Of the number of children lost, the part affected, and an operation was required, nearly the whole limb was taken away, and if the tarsal bones were the taking the cases of Giffard, Clarke, Ramsbotham, Collins, &c., one child in three and one-third was born dead-viz., in 598 subject of the same incurable disease, one half of the leg was cases, 177 children were lost." So much for the safety of sacrificed for the patient’s restoration to health. But for the science of surgery, and for the combreech presentations ! In footling and knee cases, out of 537, 205 children fell afort of those who are afflicted, it has been discovered that sacrifice. These, be it remembered, werebreech or footling: there is often no need of such extensive mutilations. It is not cases per se, and did not include all that class of cases to the removal of the limb that the surgeon now contemplates in which I have referred-namely, those necessarily made so by such cases, but the taking away merely the disease itself, and artificial assistance. leaving as much of the healthy part as is compatible with a As our octogenarian friend must have found some more successful issue. If the elbow-joint be affected he does not safe and scientific mode of manipulation in these unfortunate find it necessary to resort to amputation of the arm, but he and unnatural presentations to account for his unexampled performs resection of the ends of the bones which are diseased, success, perhaps he will favour his professional brethren with and thus leaves the patient a limb to a certain degree useful. the necessary information. The junior members will, I am If the bones of the foot be diseased, he does not amputate the sure, be grateful for any information calculated to diminish leg, but removes the affected portion at the ankle-joint, and their embarrassments; and although I have been engaged in thus allows the patient to retain the greater part of his limb, the arduous duties of an accoucheur for twenty years, I independently of giving him a better chance of his life. If the Confess I am neither too old nor too proud to receive in- greater portion even of the shaft of the tibia be affected with struction. necrosis, he does not now feel himself warranted to sacrifice the limb, but by a judicious operation, removing only that part Westminster Bridge-road, March 20th, 1848. of the bone which is dead, he will be able to bring about a cure, and save a useful member of the body. Amputation at the shoulder-joint has been performed many USE OF CHLOROFORM IN DELIRIUM TREMENS. times for caries of the head of the bone, and for fractures in that locality, but there are few well-educated surBY T. W. HOOPER, ESQ., New Peckham. geons who would think of resorting to this proceeding now, ON the 26th February, at four P.M., I was called to attend when the operation of removing the head of the bone is so well Mr. Mńń, aged forty-seven; short in stature; temperament understood, and its benefits are so universally acknowledged. sanguineo-bilious; habits intemperate: he was suffering from Resection of the. ends of bones entering into the formation of an attack of delirium tremens. On inquiry, I found he had joints, has almost entirely been confined to the elbow and been afflicted, at intervals, with the same complaint for some shoulder; and it is rather a curious and an inexplicable fact, time, and that about twelve months since he had been an that, knowing the benefits of these operations, especially that inmate of a lunatic asylum, and was still considered of un- of removing the head of the humerus, British surgeons have sound mind. not thought of putting in force an operation of a similar kind, the usual remedies for delirium tremens-viz., in another locality-namely, the hip. I prescribed is of Such common occurrence, and so opium, &c., which afforded great relief. After a sound sleep Disease of this of two hours he awoke tranquil and rational, and continued often attended with fatal results, that one would have thought so up to eleven o’clock at night, when I was again called to that the same class of excellent and observing surgeons who him. He was now very incoherent and talkative, dancing, have been conspicuous in the operative department of their singing, &c., and he could hardly be controlled by a stout art, would have recommended and put into practice some man whom I found in attendance. From the sedative effects means by which they could rescue their patients from proof chlo: oform, I considered this a case in which it might be longed suffering or inevitable death. The subject has never of service; I therefore made him inhale a drachm. From had paid to it, by most British surgeons, that due considerabeing very noisy and unmanageable, in two minutes he tion to which it is entitled, and it is only very lately that the dropped off into a quiet sleep, which continued for twenty attention of the profession has been particularly drawn to it. minutes, when he awoke calin and rational. I regret very About thirty years ago, however, Mr. Anthony White, of much that a further trial was not made, as I found he had the Westminster Hospital, met with a case of disease of the had another attack towards morning, which I have no doubt in which all the ordinary measures of cure were hip-joint, would have yielded to the application of chloroform a second found to be and in order to give his patient a time. Up to this period he has since gone on improving, by chance of unavailable; life, he deemed it fit to resort to a proceeding of a attention to his general health, and the necessity for employnovel character-namely, resection of the head of the thightag the remedy again has not arisen, bone. He put this in force, and with the most entire success, New Peckham, 1848. as will be seen by the following extract, which I take from
yImprovements I -
.
fortunately
I
compound
joint
362 Mr. Cooper’s Surgical Dictionary:—" The patient was a boy great irritation. The operation was determined upon. The whose femur had been dislocated from disease of the hip, the head, neck, and trochanters of the femur, measuring four head of the bone lying on the dorsum of the ilium. There inches and a quarter in length, were removed. Not a bad were several fistulous openings in the hip, through which the symptom ensued, and the result was most satisfactory. The bone could be detected in a state of caries. H had suffered boy was brought from the very gates of death; lie regained from the disease for three years, and was in an exhausted con- robust health and strength ; had a useful limb restored to dition. Mr. White, reflecting that the original structure of him; and now remains a wonderful instance of the benefit the joint had been annihilated, that the boy would die if no which the art and skill of the surgeon, when rightly applied, attempt was made to get rid of the diseased head of the femur,can confer. and, even if he lived, the limb fixed in this manner across the Thus, then, has this operation been revived, and to my conother would be an incumbrance only, determined to operate. viction itmaybe classed in the first rank of those great improveBeing assisted by Mr. Travers, he cut down upon, and exposed ments which have lately taken place in the operative departthe head and neck of the femur, and having sawn through the ment of our profession. But it may not appear in the same bone just below the trochanter minor, he raised the detached light to those who have not, like myself, seen its good effects, fragment with an elevator, and extracted it. At the end of a or who have not sufficiently considered the subject. It may year he recovered, and so useful a new joint had formed, that have its opponents; and on this account I havethought fitt with the assistance of a high-heeled shoe he could walk well, now to urge its consideration upon the attention of the proand execute the common movements of the limb. He lived fession, and to regard it in all its bearings. There are three considerations which I think should always :five years afterwards, and died of phthisis." The parts taken away after death were preserved, and are be entertained by the surgeon who is about to resort to some novel and severe proceeding; and the first is undoubtedly now in the Museum of the College of Surgeons, No. 391 in the Pathological department. The preparation affords a com- this,—Will it tend to ensure the safety of the patient, and plete and an interesting proof of the benefit derivable from this place him in a morefavourable condition than he was in operation. A false joint had formed, the end of the femur before? Secondly,—Will it be in accordance with the rules being securely though movably attached ta the ilium by a of science and the principles of surgery? And thirdly,Will it be likely to enhance the reputation of him who understrong capsule of ligamentous tissue. It has been supposed by some that it was Air. White, of takes it1 In order to answer the first question, it will be necessary Manchester, who performed this operation first; and I find that even M. Velpeau has made the mistake, confounding the for us to know and understand the nature of the particular two gentlemen of the same name. It is true that Mr. White, disease for which the operation may be applicable. The common malady known amongst surgeons as hipof Manchester, first counselled the operation, but he merely gave directions for the manner of performing it, as the follow- disease consists in an ulceration of the cartilages, and a ing passage from his" Cases in Surgery" testifies. He says,"I carious condition of the bones entering into the formation of have likewise, in a dead subject, made an incision on the ex- the joint. The majority of cases of this disease are found to ternal side of the hip-joint, and continued it down below the exist in children and young persons of a naturally unhealthy great trochanter, when, cutting through the bursal ligament, and scrofulous habit; and in these its chief influence appears and bringing the knee inwards, the upper head of the os to be excited upon the bone. It is particularly the head of femoris hath been forced out of its socket, and easily sawn the thigh-bone which, from its spongy structure, is more prone off, and I have no doubt that this operation might be performed than a more compact tissue to put on a low, scrofulous inflammation, and suffer consequent disorganization. If the upon a living subject with great prospect of success :’ Notwithstanding the complete success of his case, it does disease goes on increasing in severity, the powerful and renot appear that Mr. A. White has followed out his plan in any sisting ligaments of the joint become involved, and give way, succeeding instance, although, from the opportunities he has and thus a dislocation of the thigh-bone takes place. Profuse possessed of seeing disease, lie must have met with similar suppuration ensues, and matter escapes in large quantities into the surrounding tissues; communications are formed becases. Mr. Hewson, of Dublin, did perform this operation on tween the diseased parts and the integument; and thus the a patient labouring under hip disease, but the case turned out ’particularly unfortunate; there was perforation of the aceta- local malady is of a most formidable nature. But the mischief unfortunately does not terminate here; bulum, and consequently, purulent deposits in the pelvis, and the patient died. It has been said that Sir Benjamin Brodie the constitution sympathizes most acutely with the local removed the head of the femur; but I cannot obtain any accu- affection. The continual drain of matter from this large rate information respecting the correctness of this assertion. joint, and the severe pain which is an accompaniment of this The case has not, to my knowledge, ever been made public. disease, necessarily produce, as their results, great emaciation Since the period of Mr. White’s operation, with the excep- and diminution of strength, want of sleep, sweating, and tion I have mentioned, resection of the head of the thigh- cough; and the patient is gradually brought into a most bone appears to have fallen totally into oblivion amongst desperate condition. In many instances he is, after a comBritish surgeons; and the unfortunate subjects of hip-disease paratively short period of suffering, carried to the grave; or have been either allowed to die unaided by the surgeon, or to should this not be the case, he lies, perhaps for years, a helpremain helpless cripples. About three years ago, however, less and pitiable object, harassed by pain, and worn down by whilst I was studying surgery in the wards of King’s College slow and wasting hectic. It is fortunate that the foregoing is Hospital, a case of disease of the hip was admitted under Mr. not always the true picture of a case of hip-disease ; in many Fergusson ; it was impossible that any ordinary measures instances Nature, aided by the efforts of a judicious surgeon, could be of avail, and the patient was gradually sinking. To will do much. The malady may not be of so serious a chagive him a chance of life, Mr. Fergusson put in practice the racter as will resist the application of suitable remedies, and operation of White, with entire success. This case has the constitution may be powerful enough, under certain already been brought prominently before the profession;* but favourable circumstances, to bear up against its attacks, and I shall here mention its particulars. thus allow time and opportunity for those remedies to be sucA boy, aged fourteen, had been suffering for several months cessfully applied. But this favourable result cannot be exfrom disease of the hip, and had been discharged as incurable pected to take place in the moresevere cases, especially when from one of the largest hospitals in London. The malady unfavourable circumstances have existed, and when there has had made such rapid inroads upon his constitution, that it been neglect. The subjects of the disease will either die, or was evident he would sink, unless some operative proceeding they will remain in a crippled and pitiable condition for the In addition, the local symptoms were such remainder of their lives. were resorted to. as indicated that an operation might be successfully underSuch being the condition of things, then, is it not reasontaken. The head of the thigh-bone was dislocated on to the able to suppose, that by taking away the cause of these sufdorsum of the ilium, and could be felt through the soft parts ferings, even by a severeoperation, the patient will be placed lying in that situation. A large sinus was situated over the in a much more favourable state than lie was before ? No great trochanter, through which the finger could be passed, hope remains for him if the disease is allowed to go on unand carried around the articular extremity of the femur. checked; but some hope, and some considerable hope, can be Several sinuses existed contiguous to the larger one; but it held out by the surgeon, who will be bold enough to resort could not be ascertained that any led to diseased bone, or to a proceeding which is allowed to be applicable to and communicated in any way with the pelvis. The head of the justifiable in similar diseases in other parts of the body. But bone appeared to Mr. Fergusson to be acting as a foreign apart from this assertion, the operation has been performed, substance amongst the soft tissues of the hip, and thus causing life has been saved, and the patients have been restored tQ comfort and health. The second question may now be considered. Is the proTransactions for 1845. * See __
-
____________________________________
Niedico-Chirurgical
363
ceeding recommended in accordance with the rules of science existence of disease in the pelvic side of the joint, cannot cerand the principles of surgery ? One of the chief rules in tainly be entirely overcome; but I.believe that great misapsurgery I apprehend is this: that whenever any foreign sub- prehensions exist with regard to this point. Some surgeons stance is lodged or produced in any part of the body, and is suppose that in every case of hip-disease there must, of necesthere causing irritation and disease, the same should be sity, be an implication of the pelvic bones; even the celebrated removed by the art of the surgeon, if it can be got at. And Pott laboured under the mistake, for he says,In the case of how constantly does the surgeon act on this principle? He a carious hip-joint, the pelvis is never unaffected; the aceta.hesitates not, when other measures have failed, to remove, by bulum, ischii, and parts about, are always more or less in the same state, or, at least, in a distempered one, and so, indeed, a formidable and frequently fatal operation, a calculus from the bladder, which is destroying his patient’s health and most frequently are the parts within the pelvis."* If psoas or iliac abscess exist, (and iliac abscess does somecomfort. If the shoulder-joint be diseased, he deems it his duty to remove the head of the humerus, and even portions times result from disease of the hip,) an impulse will be given of the scapula; and some are bold enough even to open the on coughing or crying, and there will be other symptoms which abdomen, for the purpose of taking away ovarian tumours- more particularly belong to this affection, which the surgeon must well look into, when he is thinking about the performance an operation considered by many to be even perfectly in accordance with the rules of art ! The diseased bone must be of the operation; for should any of these be met with, it will looked upon as a foreign body, producing all the mischief; the be out of the question. indication is to remove it, and if this can be done successfully, If, then, there be dislocation of the thigh-bone, and the head it is evident that the proceeding must be regarded as one of that bone be found, either through sinuses leading to it, or entirely warrantable by science and the principles of surgery. through an opening in an abscess, to be extensively diseased, If these two questions are satisfactorily answered, the third and if after accurate examination it be ascertained that there will be also; for any proceeding which is conducted for the is no disease of importance in the pelvic bones, and no comrelief of suffering, and on scientific and correct principles, munication between the abscesses about the hip, nor any with will redound to the credit of him who undertakes it, and the pelvis or abdomen: it, also, with these conditions, it be will, amongst right-thinking and impartial men at least, in- evident that the patient is slowly and gradually sinking under his malady, and the surgeon is convinced that there is no hope crease his reputation. But it requires great care and the exercise of a sound judg- for him from natural and remedial means, but that he can ment to determine upon the proper cases in which this severe hold out considerable hope by the adoption of a proceeding, operation should be attempted. It is this, and not so much severe indeed, but not so formidable as is imagined; then will the manual proceeding, which constitutes the difficulty of it be both justifiable and proper to have recourse to this opethe subject; for if extreme caution and watchful observation ration ; and I think it is the duty of the surgeon, in such a. be not employed in the selection of the cases, yet the opera- state of things, to give his patient a chance of life, and not to tion be put in force, it will only aggravate the sufferings of the suffer him to die, unaided by those resources which are expatient, and injure the character of the surgeon. It must be pected to be in his possession. I will now proceed to state how this operation may be perremembered, that it is not every incurable disease of the hipappear to those who havenot thought joint for which this remedy will be suitable. I shall speak formed. It perhaps may to correctly, perhaps, if I say that it is not applicable to the about the matter before, be one of a formidable and difficult majority of these cases; for it is only under particular circum- nature. I recollect when Mr. Fergusson was about to perform stances that resection of the head of the femur should be it, three yearsago, that it struck me as being something of a. attempted. The disease in the hip must be in its last stage; very fearful character, but having seen it performed on the it is necessary that dislocation of the thigh-bone from its living subject, and having carefully studied it on the dead socket should have taken place, and there must be evidence body, I have, I believe, arrived at a more correct opinion. of the disease being confined chiefly to the upper part of this Although it requires great care and determination on the part bone, and of a non-implication to any great extent of the pelvic of him who undertakes it, at the same time there is nothing in the nature and extent of the operation itself, which should bones. The symptoms of the last stage of hip-disease, and of dislo- prove a hindrance to its performance in a proper case, and in cation, are sufficiently well known to my readers, and it is not the hands of a well-educated surgeon. In the dead subject, the head of the femur may be removed necessary for me to enumerate them. At the same time I would have the surgeon not to be to’o hasty in making up his in the following manner:-An incision should be carried from mind as to the existence of dislocation, for there are cases to below the great trochanter, upwards, towards the crest of the be met with in which the signs are deceptive. The distorted ilium, for four inches. The muscles covering the joint, and aspect of the hip, and the shortening of the limb, may lead attached to the trochanters, should be divided, and the caphim to suppose that dislocation exists, especially if the disease sular ligament exposed: this part of the operation will be has been of long standing. Notwithstanding these symptoms, facilitated by making a second incision, at right angles to the however, the head of the bone may yet be in its socket, either first. The capsule should then be freely opened from above, unaffected by the disease confined to the neck and trochanter, and the limb being carried across the other, the head of the or in a state of partial ankylosis. This occasional difficulty of bone will start from its socket. The soft parts adherent to diagnosis will not stand in the way however, as few surgeons the bone should be then well cleared away, and a common think of performing this operation, except in those cases saw being applied, the requisite section may be made. would This proceeding, when executed upon the dead subject, and in which it is evident to the eye and the finger that the head of the bone has slipped from its natural situation, and is in a when the parts are in their natural and healthy condition, carious condition. If in such a case the disease has existed is certainly difficult. When the parts, however, are in that for a considerable time, abscess and sinuses will have formed, state which I have mentioned, as existing when the operation and through the latter, by means of the finger or the probe, is required, it will be rendered more easy. The head of the the head of the bone may be felt, and the amount of disease bone, instead of being closely concealed in its deep and overdetected. An abscess may exist in this region, and by eva- hanging socket, and kept there by its powerful ligaments, lies cuating it, the same object may be gained; the head of the readily within reach, in a more prominent position; and the bone will, in some instances, be found lying in the midst of soft parts, from being wasted and disorganized, present less this abscess, on the ilium, and the finger may readily be carried resistance. over its surface. To what extent the pelvic side of the joint Various methods have been proposed for performing this may be diseased will be a more difficult thing to ascertain, and operation on the living body; incisions of various forms have there are, perhaps, no signs by which we can to a certainty been recommended and put in practice. Of all these methods, learn this. If, however, much disease exist there, sinuses will that which is put in practice by Mr. Fergusson appears to me be formed over the parts, and by means of them some correct to be the most applicable. In the report of his first case, he information may be gained. Sometimes the acetabulum in states, " An incision through the skin and other tissues (six these bad cases is completely perforated, and matter gets into inches in length, carried over the trochanter) enabled me to the pelvic cavity; in this case a considerable impulse will be expose the portion of the femur which I, had resolved to given to any collection of matter which may exist superficially remove; the head, neck, and trochanter major were isolated and thoroughly turned out of the wound, by twisting the limb on the patient’s coughing, and the local and general symptoms will be much more severe. By looking at the anus and rectum over the opposite thigh; and a common saw enabled me to the surgeon may sometimes be assisted in his diagnosis; for it effect the separation of four inches and a quarter of the occasionally happens that when the ulceration extends through bone." In this case it will be seen, that not only the head of the the acetabulum, and matter passes into the pelvis, it descends, to the sides of the more fistulous or * by openings, readily anus, Pott’s Surgery, vol. iii. p. 412. into the rectum. This objection to the operation-namely, the &dag er; Fergusson’s Surgery. Second edition, p. 382.
364 but the great trochanter, also, was removed, in consequence of a supposition that the disease extended so far:: thus the reason for so long an incision.
’/syth)
"The first particular worthy of notice (remarks Dr. Foris the comparative rarity of fevers in Nova Scotia, as contrasted with Great Britain, though I readily acknowledge If the head of the bone alone is to be removed, a shorter myself unpreparedfully to estimate the difference, my obserincision of from three to four inches will suffice. If the! vation in Britain having been limited to the large towns of surgeon requires more room to work in, as, for instance, in: Scotland. In Nova Scotia no towns of any consequence exist, the application of his saw, a second incision may be made, to except Halifax, which contains a population of 22,000; yet there the inhabitants are as healthy, to appearance, and as free cross the first, a proceeding I have lately seen Mr. Fergusson put into practice. Care must be taken not to injure the great from sickness, as in the rural districts. In the table, only 199 sciatic nerve, which will be found somewhat in the way. The cases of fever in all are recorded, of which much the larger bleeding will probably require little attention; no ligaturesI number are eruptive, only twenty-nine belonging to the ordiwere required in those cases which have fallen under my own nary continued typhoid type." " Continued fever is generally very similar to what is occaobservation. It is highly necessary that the surgeon should look to the sionally seen in hospital practice in Britain, as amongst condition of the cotyloid cavity; and as far as I can ascertain, servants and those who have been well fed and in comfortthis important point has not been insisted upon, except by able residence, requiring moderate depletion and abstinence. Mr. Fergusson. If it be found not involved in the disease, In its other form it exhibits symptoms of excitement in its the operation is finished; but if the edges of this cavity be early stage, and runs a longer course, often with very decided carious, the cutting pliers should be used, and the unhealthy typhoid symptoms in its latter stage. It is generally quite portions taken away; and should any part of the socket itselfamenable to treatment, except when the subject of it is in unbe in the same condition, it should be taken away by means ofcomfortable quarters, and where the vicissitudes of the weather the gouge. No surgeon should attempt to perform this opera- cannot be guarded against. In such a case, pneumonia or some tion, unless he has in readiness these two, most useful instru- other inflammatory action being induced, it sometimes proves ments. fatal, especially in scrofulous constitutions. The petechial The after treatment is to be conducted on the ordinary eruption, so prevalent in Glasgow and Edinburgh, seldom principles of surgery, but particular attention should be paid occurs here. On dissection, the usual inflammatory engorgeto the position of the limb; it should be kept straight, and ment and ulceration of Peyer’s glands exist. It cannot, howextended as much as possible. If the case does well, the ever, be said that we have any of the low typhus fever, so prepatient gradually loses his night sweats and restlessness; the valent in North Britain,where the animal heat, instead of being discharge of matter diminishes; and sinuses which may have above the standard of health, was found by the writer, in existed slowly close up. Under these circumstances, it may hundreds of cases, during the year 1832, to have been below be fairly presumed that every source of irritation has been it-often down to 940 Fahr. Possibly the depression was taken away. greater than ordinary during that year, it being the period (To be continued.) during which the epidemic cholera extended - its fearful ravages through that part of the United Kingdom." The most prevalent fevers are the eruptive, as scarlatina, measles, and occasionally small pox; the two former spread OF through the province epidemically every five or six years, or the latter occurs less frequently, but it has sometimes COMMUNICATIONS IN MS. RECEIVED FOR oftener; caused great desolation in Halifax. The two cases of intermittent fever are stated to have been imported from the PUBLICATION IN THE LANCET. United States, and Dr. Forsyth asserts that he cannot learn that ague had at any period originated in the province. He Remarks on Diseases in Nova Scotia. remarks, however," By J. E. FORSYTH, M.D., Glasgow. A well-marked case occurred within the
bone,
’
.
. ’
,
Analyses
FORMERLY HOUSE-SURGEON TO GLASGOW ROYAL INFIRMARY.
A
TABLE
of 1405
cases
of disease
occurring between
1840 and
1846,ina population of 15,000 persons, inhabiting King’s County, Nova Scotia, presents the following particulars:-Instances of abscess, 22; amenorrheea, 13; fistula and prolapsus ani, 12; bronchitis, 52; carcinoma, 6; pulmonary catarrh, 39; chlorosis, 12; cholera, 13; colic, 15; dysentery, 14; epilepsy, 15; erysipelas, 21; fever, continued, 19; typhoid, 10; intermittent, 2; infantile remittent, 33; puerperal, 4; gastrodynia, 11; haemorrhages, 14; hernia, 13; hooping-cough, 21; hysteria, 19; indigestion, 123; influenza, 26; insanity, 11; leucorrhcoa, 10; menorrhagia, 9; ophthalmia, 22; otitis and otorrhcea, 10; tubercular phthisis, 15; plethora, 12; pleurisy, 28; pneumonia, 40; psoriasis, 13; purpura, 2; rheumatism, 36; rickets, 2; rubeola, 45; scabies, 22; scarlatina, 80; strumous glands, 6; small-pox, 6; tabes mesenterica, 3; throat, inflammations of, 28; ulcers, 11. We have extracted as above, from the table alluded to, the relative numbers of the more prevalent diseases, and of such as are the most obviously connected with the influence of climate. King’s County, Nova Scotia, is an agricultural district, about forty miles in length, by twenty miles in breadth, at the angle formed by the Bay of Fundy and the Gulf of Minas, and skirted on the bay shore by a narrow range of highlands, 300 feet above the sea, from which several small parallel streams flow into the Basin of Minas. Up the course of these streams the tide waters of the basin formerly flowed, in some instances, for six or eight miles, but they are now generally excluded by dykes, with sluices and flood-gates, and about 8000 acres of the richest alluvial land have been thus rescued from the tides, which in the Basin of Minas are said to rise from fifty to sixty feet. The diluvial land called intervale, situated on the small streams in the interior of the scarcely less extensive. The remaining upland portion county.is is partly under cultivation, and partly covered with forest. The province being a peninsula the climate is milder than in other parts of North America of the same latitude, and though the thermometric range is much greater between summer and winter than in Britain, and occasionally varies greatly from one day to another, yet it is dry and salubrious, with an atmosphere generally clear in the interior.
my knowledge, of which had resided about a twelvemonth in the State of Ohio, on a visit. He enjoyed, he says, uninterrupted good health, while there, and for six months after his return home, but on making a fatiguing journey through the province, early in the spring, (our most changeable and unhealthy season,) was seized with a well-marked tertian ague ! Could the germs of the disease have remained latent during the period of six months? "The only remittent fever observed here within my knowledge is the infantile remittent, and if Dr. Copland’s opinion be correct, (as I presume it is,)’that a more concentrated form, or intense action of the causes exciting the ague, is necessary to induce the remittent of adults,’ it follows, as a matter of course, that the latter could not occur here under any ordinary circumstances. Asthe infantile remittent fever is of rather frequent occurrence, it may be inferred by some thatmarsh miasm’ might be present, sufficient to induce this disease in children, though not to the degree of exciting either or the remittent of adults. ague " Nova Scotia, by reason of its geographical position, is fortunately exempt from the yellow fever, which at different times has proved such a scourge to the more southern portion of North America. It has been but rarely introduced from the West Indies; and on one such occasion only, and that during hot weather, two cases are said to have sickened while on board the ship after arrival in port, but on landing the crew it spread no farther. These, the only authenticated instances of its occurrence here, were obviously caused poisonous effluvia of the ship, favoured by the heat. They could scarcely have occurred in the autumn (the chief season of our continued fever,) on account of the lowness of temperature, and our winter affords a perfect security. " As might be inferred, a priori, from the great and often sudden changes of temperature, the ’phlegmasiae’ constitute the largest order of diseases in Nova Scotia; and as the respiratory organs are primarily exposed to atmospheric influences, it is not to be wondered at that diseases of the lungs and their appendages should constitute a very large proportion of the inflammations of this climate. Amongst the more important of these, as regards frequency and danger, may be enumerated
subject
by the
yImprovements I -
.
fortunately
I
compound
joint
362 Mr. Cooper’s Surgical Dictionary:—" The patient was a boy great irritation. The operation was determined upon. The whose femur had been dislocated from disease of the hip, the head, neck, and trochanters of the femur, measuring four head of the bone lying on the dorsum of the ilium. There inches and a quarter in length, were removed. Not a bad were several fistulous openings in the hip, through which the symptom ensued, and the result was most satisfactory. The bone could be detected in a state of caries. H had suffered boy was brought from the very gates of death; lie regained from the disease for three years, and was in an exhausted con- robust health and strength ; had a useful limb restored to dition. Mr. White, reflecting that the original structure of him; and now remains a wonderful instance of the benefit the joint had been annihilated, that the boy would die if no which the art and skill of the surgeon, when rightly applied, attempt was made to get rid of the diseased head of the femur,can confer. and, even if he lived, the limb fixed in this manner across the Thus, then, has this operation been revived, and to my conother would be an incumbrance only, determined to operate. viction itmaybe classed in the first rank of those great improveBeing assisted by Mr. Travers, he cut down upon, and exposed ments which have lately taken place in the operative departthe head and neck of the femur, and having sawn through the ment of our profession. But it may not appear in the same bone just below the trochanter minor, he raised the detached light to those who have not, like myself, seen its good effects, fragment with an elevator, and extracted it. At the end of a or who have not sufficiently considered the subject. It may year he recovered, and so useful a new joint had formed, that have its opponents; and on this account I havethought fitt with the assistance of a high-heeled shoe he could walk well, now to urge its consideration upon the attention of the proand execute the common movements of the limb. He lived fession, and to regard it in all its bearings. There are three considerations which I think should always :five years afterwards, and died of phthisis." The parts taken away after death were preserved, and are be entertained by the surgeon who is about to resort to some novel and severe proceeding; and the first is undoubtedly now in the Museum of the College of Surgeons, No. 391 in the Pathological department. The preparation affords a com- this,—Will it tend to ensure the safety of the patient, and plete and an interesting proof of the benefit derivable from this place him in a morefavourable condition than he was in operation. A false joint had formed, the end of the femur before? Secondly,—Will it be in accordance with the rules being securely though movably attached ta the ilium by a of science and the principles of surgery? And thirdly,Will it be likely to enhance the reputation of him who understrong capsule of ligamentous tissue. It has been supposed by some that it was Air. White, of takes it1 In order to answer the first question, it will be necessary Manchester, who performed this operation first; and I find that even M. Velpeau has made the mistake, confounding the for us to know and understand the nature of the particular two gentlemen of the same name. It is true that Mr. White, disease for which the operation may be applicable. The common malady known amongst surgeons as hipof Manchester, first counselled the operation, but he merely gave directions for the manner of performing it, as the follow- disease consists in an ulceration of the cartilages, and a ing passage from his" Cases in Surgery" testifies. He says,"I carious condition of the bones entering into the formation of have likewise, in a dead subject, made an incision on the ex- the joint. The majority of cases of this disease are found to ternal side of the hip-joint, and continued it down below the exist in children and young persons of a naturally unhealthy great trochanter, when, cutting through the bursal ligament, and scrofulous habit; and in these its chief influence appears and bringing the knee inwards, the upper head of the os to be excited upon the bone. It is particularly the head of femoris hath been forced out of its socket, and easily sawn the thigh-bone which, from its spongy structure, is more prone off, and I have no doubt that this operation might be performed than a more compact tissue to put on a low, scrofulous inflammation, and suffer consequent disorganization. If the upon a living subject with great prospect of success :’ Notwithstanding the complete success of his case, it does disease goes on increasing in severity, the powerful and renot appear that Mr. A. White has followed out his plan in any sisting ligaments of the joint become involved, and give way, succeeding instance, although, from the opportunities he has and thus a dislocation of the thigh-bone takes place. Profuse possessed of seeing disease, lie must have met with similar suppuration ensues, and matter escapes in large quantities into the surrounding tissues; communications are formed becases. Mr. Hewson, of Dublin, did perform this operation on tween the diseased parts and the integument; and thus the a patient labouring under hip disease, but the case turned out ’particularly unfortunate; there was perforation of the aceta- local malady is of a most formidable nature. But the mischief unfortunately does not terminate here; bulum, and consequently, purulent deposits in the pelvis, and the patient died. It has been said that Sir Benjamin Brodie the constitution sympathizes most acutely with the local removed the head of the femur; but I cannot obtain any accu- affection. The continual drain of matter from this large rate information respecting the correctness of this assertion. joint, and the severe pain which is an accompaniment of this The case has not, to my knowledge, ever been made public. disease, necessarily produce, as their results, great emaciation Since the period of Mr. White’s operation, with the excep- and diminution of strength, want of sleep, sweating, and tion I have mentioned, resection of the head of the thigh- cough; and the patient is gradually brought into a most bone appears to have fallen totally into oblivion amongst desperate condition. In many instances he is, after a comBritish surgeons; and the unfortunate subjects of hip-disease paratively short period of suffering, carried to the grave; or have been either allowed to die unaided by the surgeon, or to should this not be the case, he lies, perhaps for years, a helpremain helpless cripples. About three years ago, however, less and pitiable object, harassed by pain, and worn down by whilst I was studying surgery in the wards of King’s College slow and wasting hectic. It is fortunate that the foregoing is Hospital, a case of disease of the hip was admitted under Mr. not always the true picture of a case of hip-disease ; in many Fergusson ; it was impossible that any ordinary measures instances Nature, aided by the efforts of a judicious surgeon, could be of avail, and the patient was gradually sinking. To will do much. The malady may not be of so serious a chagive him a chance of life, Mr. Fergusson put in practice the racter as will resist the application of suitable remedies, and operation of White, with entire success. This case has the constitution may be powerful enough, under certain already been brought prominently before the profession;* but favourable circumstances, to bear up against its attacks, and I shall here mention its particulars. thus allow time and opportunity for those remedies to be sucA boy, aged fourteen, had been suffering for several months cessfully applied. But this favourable result cannot be exfrom disease of the hip, and had been discharged as incurable pected to take place in the moresevere cases, especially when from one of the largest hospitals in London. The malady unfavourable circumstances have existed, and when there has had made such rapid inroads upon his constitution, that it been neglect. The subjects of the disease will either die, or was evident he would sink, unless some operative proceeding they will remain in a crippled and pitiable condition for the In addition, the local symptoms were such remainder of their lives. were resorted to. as indicated that an operation might be successfully underSuch being the condition of things, then, is it not reasontaken. The head of the thigh-bone was dislocated on to the able to suppose, that by taking away the cause of these sufdorsum of the ilium, and could be felt through the soft parts ferings, even by a severeoperation, the patient will be placed lying in that situation. A large sinus was situated over the in a much more favourable state than lie was before ? No great trochanter, through which the finger could be passed, hope remains for him if the disease is allowed to go on unand carried around the articular extremity of the femur. checked; but some hope, and some considerable hope, can be Several sinuses existed contiguous to the larger one; but it held out by the surgeon, who will be bold enough to resort could not be ascertained that any led to diseased bone, or to a proceeding which is allowed to be applicable to and communicated in any way with the pelvis. The head of the justifiable in similar diseases in other parts of the body. But bone appeared to Mr. Fergusson to be acting as a foreign apart from this assertion, the operation has been performed, substance amongst the soft tissues of the hip, and thus causing life has been saved, and the patients have been restored tQ comfort and health. The second question may now be considered. Is the proTransactions for 1845. * See __
-
____________________________________
Niedico-Chirurgical
363
ceeding recommended in accordance with the rules of science existence of disease in the pelvic side of the joint, cannot cerand the principles of surgery ? One of the chief rules in tainly be entirely overcome; but I.believe that great misapsurgery I apprehend is this: that whenever any foreign sub- prehensions exist with regard to this point. Some surgeons stance is lodged or produced in any part of the body, and is suppose that in every case of hip-disease there must, of necesthere causing irritation and disease, the same should be sity, be an implication of the pelvic bones; even the celebrated removed by the art of the surgeon, if it can be got at. And Pott laboured under the mistake, for he says,In the case of how constantly does the surgeon act on this principle? He a carious hip-joint, the pelvis is never unaffected; the aceta.hesitates not, when other measures have failed, to remove, by bulum, ischii, and parts about, are always more or less in the same state, or, at least, in a distempered one, and so, indeed, a formidable and frequently fatal operation, a calculus from the bladder, which is destroying his patient’s health and most frequently are the parts within the pelvis."* If psoas or iliac abscess exist, (and iliac abscess does somecomfort. If the shoulder-joint be diseased, he deems it his duty to remove the head of the humerus, and even portions times result from disease of the hip,) an impulse will be given of the scapula; and some are bold enough even to open the on coughing or crying, and there will be other symptoms which abdomen, for the purpose of taking away ovarian tumours- more particularly belong to this affection, which the surgeon must well look into, when he is thinking about the performance an operation considered by many to be even perfectly in accordance with the rules of art ! The diseased bone must be of the operation; for should any of these be met with, it will looked upon as a foreign body, producing all the mischief; the be out of the question. indication is to remove it, and if this can be done successfully, If, then, there be dislocation of the thigh-bone, and the head it is evident that the proceeding must be regarded as one of that bone be found, either through sinuses leading to it, or entirely warrantable by science and the principles of surgery. through an opening in an abscess, to be extensively diseased, If these two questions are satisfactorily answered, the third and if after accurate examination it be ascertained that there will be also; for any proceeding which is conducted for the is no disease of importance in the pelvic bones, and no comrelief of suffering, and on scientific and correct principles, munication between the abscesses about the hip, nor any with will redound to the credit of him who undertakes it, and the pelvis or abdomen: it, also, with these conditions, it be will, amongst right-thinking and impartial men at least, in- evident that the patient is slowly and gradually sinking under his malady, and the surgeon is convinced that there is no hope crease his reputation. But it requires great care and the exercise of a sound judg- for him from natural and remedial means, but that he can ment to determine upon the proper cases in which this severe hold out considerable hope by the adoption of a proceeding, operation should be attempted. It is this, and not so much severe indeed, but not so formidable as is imagined; then will the manual proceeding, which constitutes the difficulty of it be both justifiable and proper to have recourse to this opethe subject; for if extreme caution and watchful observation ration ; and I think it is the duty of the surgeon, in such a. be not employed in the selection of the cases, yet the opera- state of things, to give his patient a chance of life, and not to tion be put in force, it will only aggravate the sufferings of the suffer him to die, unaided by those resources which are expatient, and injure the character of the surgeon. It must be pected to be in his possession. I will now proceed to state how this operation may be perremembered, that it is not every incurable disease of the hipappear to those who havenot thought joint for which this remedy will be suitable. I shall speak formed. It perhaps may to correctly, perhaps, if I say that it is not applicable to the about the matter before, be one of a formidable and difficult majority of these cases; for it is only under particular circum- nature. I recollect when Mr. Fergusson was about to perform stances that resection of the head of the femur should be it, three yearsago, that it struck me as being something of a. attempted. The disease in the hip must be in its last stage; very fearful character, but having seen it performed on the it is necessary that dislocation of the thigh-bone from its living subject, and having carefully studied it on the dead socket should have taken place, and there must be evidence body, I have, I believe, arrived at a more correct opinion. of the disease being confined chiefly to the upper part of this Although it requires great care and determination on the part bone, and of a non-implication to any great extent of the pelvic of him who undertakes it, at the same time there is nothing in the nature and extent of the operation itself, which should bones. The symptoms of the last stage of hip-disease, and of dislo- prove a hindrance to its performance in a proper case, and in cation, are sufficiently well known to my readers, and it is not the hands of a well-educated surgeon. In the dead subject, the head of the femur may be removed necessary for me to enumerate them. At the same time I would have the surgeon not to be to’o hasty in making up his in the following manner:-An incision should be carried from mind as to the existence of dislocation, for there are cases to below the great trochanter, upwards, towards the crest of the be met with in which the signs are deceptive. The distorted ilium, for four inches. The muscles covering the joint, and aspect of the hip, and the shortening of the limb, may lead attached to the trochanters, should be divided, and the caphim to suppose that dislocation exists, especially if the disease sular ligament exposed: this part of the operation will be has been of long standing. Notwithstanding these symptoms, facilitated by making a second incision, at right angles to the however, the head of the bone may yet be in its socket, either first. The capsule should then be freely opened from above, unaffected by the disease confined to the neck and trochanter, and the limb being carried across the other, the head of the or in a state of partial ankylosis. This occasional difficulty of bone will start from its socket. The soft parts adherent to diagnosis will not stand in the way however, as few surgeons the bone should be then well cleared away, and a common think of performing this operation, except in those cases saw being applied, the requisite section may be made. would This proceeding, when executed upon the dead subject, and in which it is evident to the eye and the finger that the head of the bone has slipped from its natural situation, and is in a when the parts are in their natural and healthy condition, carious condition. If in such a case the disease has existed is certainly difficult. When the parts, however, are in that for a considerable time, abscess and sinuses will have formed, state which I have mentioned, as existing when the operation and through the latter, by means of the finger or the probe, is required, it will be rendered more easy. The head of the the head of the bone may be felt, and the amount of disease bone, instead of being closely concealed in its deep and overdetected. An abscess may exist in this region, and by eva- hanging socket, and kept there by its powerful ligaments, lies cuating it, the same object may be gained; the head of the readily within reach, in a more prominent position; and the bone will, in some instances, be found lying in the midst of soft parts, from being wasted and disorganized, present less this abscess, on the ilium, and the finger may readily be carried resistance. over its surface. To what extent the pelvic side of the joint Various methods have been proposed for performing this may be diseased will be a more difficult thing to ascertain, and operation on the living body; incisions of various forms have there are, perhaps, no signs by which we can to a certainty been recommended and put in practice. Of all these methods, learn this. If, however, much disease exist there, sinuses will that which is put in practice by Mr. Fergusson appears to me be formed over the parts, and by means of them some correct to be the most applicable. In the report of his first case, he information may be gained. Sometimes the acetabulum in states, " An incision through the skin and other tissues (six these bad cases is completely perforated, and matter gets into inches in length, carried over the trochanter) enabled me to the pelvic cavity; in this case a considerable impulse will be expose the portion of the femur which I, had resolved to given to any collection of matter which may exist superficially remove; the head, neck, and trochanter major were isolated and thoroughly turned out of the wound, by twisting the limb on the patient’s coughing, and the local and general symptoms will be much more severe. By looking at the anus and rectum over the opposite thigh; and a common saw enabled me to the surgeon may sometimes be assisted in his diagnosis; for it effect the separation of four inches and a quarter of the occasionally happens that when the ulceration extends through bone." In this case it will be seen, that not only the head of the the acetabulum, and matter passes into the pelvis, it descends, to the sides of the more fistulous or * by openings, readily anus, Pott’s Surgery, vol. iii. p. 412. into the rectum. This objection to the operation-namely, the &dag er; Fergusson’s Surgery. Second edition, p. 382.
364 but the great trochanter, also, was removed, in consequence of a supposition that the disease extended so far:: thus the reason for so long an incision.
’/syth)
"The first particular worthy of notice (remarks Dr. Foris the comparative rarity of fevers in Nova Scotia, as contrasted with Great Britain, though I readily acknowledge If the head of the bone alone is to be removed, a shorter myself unpreparedfully to estimate the difference, my obserincision of from three to four inches will suffice. If the! vation in Britain having been limited to the large towns of surgeon requires more room to work in, as, for instance, in: Scotland. In Nova Scotia no towns of any consequence exist, the application of his saw, a second incision may be made, to except Halifax, which contains a population of 22,000; yet there the inhabitants are as healthy, to appearance, and as free cross the first, a proceeding I have lately seen Mr. Fergusson put into practice. Care must be taken not to injure the great from sickness, as in the rural districts. In the table, only 199 sciatic nerve, which will be found somewhat in the way. The cases of fever in all are recorded, of which much the larger bleeding will probably require little attention; no ligaturesI number are eruptive, only twenty-nine belonging to the ordiwere required in those cases which have fallen under my own nary continued typhoid type." " Continued fever is generally very similar to what is occaobservation. It is highly necessary that the surgeon should look to the sionally seen in hospital practice in Britain, as amongst condition of the cotyloid cavity; and as far as I can ascertain, servants and those who have been well fed and in comfortthis important point has not been insisted upon, except by able residence, requiring moderate depletion and abstinence. Mr. Fergusson. If it be found not involved in the disease, In its other form it exhibits symptoms of excitement in its the operation is finished; but if the edges of this cavity be early stage, and runs a longer course, often with very decided carious, the cutting pliers should be used, and the unhealthy typhoid symptoms in its latter stage. It is generally quite portions taken away; and should any part of the socket itselfamenable to treatment, except when the subject of it is in unbe in the same condition, it should be taken away by means ofcomfortable quarters, and where the vicissitudes of the weather the gouge. No surgeon should attempt to perform this opera- cannot be guarded against. In such a case, pneumonia or some tion, unless he has in readiness these two, most useful instru- other inflammatory action being induced, it sometimes proves ments. fatal, especially in scrofulous constitutions. The petechial The after treatment is to be conducted on the ordinary eruption, so prevalent in Glasgow and Edinburgh, seldom principles of surgery, but particular attention should be paid occurs here. On dissection, the usual inflammatory engorgeto the position of the limb; it should be kept straight, and ment and ulceration of Peyer’s glands exist. It cannot, howextended as much as possible. If the case does well, the ever, be said that we have any of the low typhus fever, so prepatient gradually loses his night sweats and restlessness; the valent in North Britain,where the animal heat, instead of being discharge of matter diminishes; and sinuses which may have above the standard of health, was found by the writer, in existed slowly close up. Under these circumstances, it may hundreds of cases, during the year 1832, to have been below be fairly presumed that every source of irritation has been it-often down to 940 Fahr. Possibly the depression was taken away. greater than ordinary during that year, it being the period (To be continued.) during which the epidemic cholera extended - its fearful ravages through that part of the United Kingdom." The most prevalent fevers are the eruptive, as scarlatina, measles, and occasionally small pox; the two former spread OF through the province epidemically every five or six years, or the latter occurs less frequently, but it has sometimes COMMUNICATIONS IN MS. RECEIVED FOR oftener; caused great desolation in Halifax. The two cases of intermittent fever are stated to have been imported from the PUBLICATION IN THE LANCET. United States, and Dr. Forsyth asserts that he cannot learn that ague had at any period originated in the province. He Remarks on Diseases in Nova Scotia. remarks, however," By J. E. FORSYTH, M.D., Glasgow. A well-marked case occurred within the
bone,
’
.
. ’
,
Analyses
FORMERLY HOUSE-SURGEON TO GLASGOW ROYAL INFIRMARY.
A
TABLE
of 1405
cases
of disease
occurring between
1840 and
1846,ina population of 15,000 persons, inhabiting King’s County, Nova Scotia, presents the following particulars:-Instances of abscess, 22; amenorrheea, 13; fistula and prolapsus ani, 12; bronchitis, 52; carcinoma, 6; pulmonary catarrh, 39; chlorosis, 12; cholera, 13; colic, 15; dysentery, 14; epilepsy, 15; erysipelas, 21; fever, continued, 19; typhoid, 10; intermittent, 2; infantile remittent, 33; puerperal, 4; gastrodynia, 11; haemorrhages, 14; hernia, 13; hooping-cough, 21; hysteria, 19; indigestion, 123; influenza, 26; insanity, 11; leucorrhcoa, 10; menorrhagia, 9; ophthalmia, 22; otitis and otorrhcea, 10; tubercular phthisis, 15; plethora, 12; pleurisy, 28; pneumonia, 40; psoriasis, 13; purpura, 2; rheumatism, 36; rickets, 2; rubeola, 45; scabies, 22; scarlatina, 80; strumous glands, 6; small-pox, 6; tabes mesenterica, 3; throat, inflammations of, 28; ulcers, 11. We have extracted as above, from the table alluded to, the relative numbers of the more prevalent diseases, and of such as are the most obviously connected with the influence of climate. King’s County, Nova Scotia, is an agricultural district, about forty miles in length, by twenty miles in breadth, at the angle formed by the Bay of Fundy and the Gulf of Minas, and skirted on the bay shore by a narrow range of highlands, 300 feet above the sea, from which several small parallel streams flow into the Basin of Minas. Up the course of these streams the tide waters of the basin formerly flowed, in some instances, for six or eight miles, but they are now generally excluded by dykes, with sluices and flood-gates, and about 8000 acres of the richest alluvial land have been thus rescued from the tides, which in the Basin of Minas are said to rise from fifty to sixty feet. The diluvial land called intervale, situated on the small streams in the interior of the scarcely less extensive. The remaining upland portion county.is is partly under cultivation, and partly covered with forest. The province being a peninsula the climate is milder than in other parts of North America of the same latitude, and though the thermometric range is much greater between summer and winter than in Britain, and occasionally varies greatly from one day to another, yet it is dry and salubrious, with an atmosphere generally clear in the interior.
my knowledge, of which had resided about a twelvemonth in the State of Ohio, on a visit. He enjoyed, he says, uninterrupted good health, while there, and for six months after his return home, but on making a fatiguing journey through the province, early in the spring, (our most changeable and unhealthy season,) was seized with a well-marked tertian ague ! Could the germs of the disease have remained latent during the period of six months? "The only remittent fever observed here within my knowledge is the infantile remittent, and if Dr. Copland’s opinion be correct, (as I presume it is,)’that a more concentrated form, or intense action of the causes exciting the ague, is necessary to induce the remittent of adults,’ it follows, as a matter of course, that the latter could not occur here under any ordinary circumstances. Asthe infantile remittent fever is of rather frequent occurrence, it may be inferred by some thatmarsh miasm’ might be present, sufficient to induce this disease in children, though not to the degree of exciting either or the remittent of adults. ague " Nova Scotia, by reason of its geographical position, is fortunately exempt from the yellow fever, which at different times has proved such a scourge to the more southern portion of North America. It has been but rarely introduced from the West Indies; and on one such occasion only, and that during hot weather, two cases are said to have sickened while on board the ship after arrival in port, but on landing the crew it spread no farther. These, the only authenticated instances of its occurrence here, were obviously caused poisonous effluvia of the ship, favoured by the heat. They could scarcely have occurred in the autumn (the chief season of our continued fever,) on account of the lowness of temperature, and our winter affords a perfect security. " As might be inferred, a priori, from the great and often sudden changes of temperature, the ’phlegmasiae’ constitute the largest order of diseases in Nova Scotia; and as the respiratory organs are primarily exposed to atmospheric influences, it is not to be wondered at that diseases of the lungs and their appendages should constitute a very large proportion of the inflammations of this climate. Amongst the more important of these, as regards frequency and danger, may be enumerated
subject
by the