venous with the arterial current, the latter being that which has obtained most advocacy in this country. That Dr. Hunter's explanation is not universally applicable, appears to us proved by the fact that cyanosis has not always been observed even when, from the existence of great imperfection, there can be no doubt that a free admixture of the currents of blood must have existed from the time of birth. Recent disease of the heart and lungs will often lead to the development of cyanosis in cases of this kind, and the post-mortem examination alone reveals the existence of the congenital defect.

In taking leave of this work, we would only add that the author has enriched it with the details of no less than eighteen original cases, and, in addition, has given analyses of or references to all the principal examples of the abnormal conditions of which he has treated. The present edition contains also eight admirable lithographic plates. We congratulate Dr. Peacock on the execution of his very valuable work. It is a performance which reflects credit on the author, and through him on the Society of which he has lately been president.

REVIEW III.

On Joint Diseases; their Pathology, Diagnosis, and Treatment; including the Nature and Treatment of Deformities and Curvatures of the Spine. By HOLMES COOTE, F.R.C.S., Surgeon to St. Bartholomew's Hospital, Consulting Surgeon to the National Orthopedic Hospital, &c. London: Hardwicke. 1867. 8vo, pp. 299.

THE study of joint diseases has occupied the attention of many of our most distinguished surgeons; and if we recall the names of those who have contributed to our knowledge of this subject, we shall find that they include some of the brightest ornaments of modern surgery. Indeed, this could hardly fail to be the case; for diseases of the joints are of such frequent occurrence, they are so serious in their results, and their pathology presents so many points of interest, that it would have been strange if they had not attracted a large share of professional attention. The joints of the human body are so numerous, they are so constantly in action, and their mechanism is so delicate and complicated, that it is not wonderful that they should be liable to a [great variety of mischances. But in this country, where the different forms of scrofula are so common, the

diseases of joints present a still higher degree of importance; for it is hardly too much to say that of the many cases of joint disease which come under the notice of English surgeons, a majority have their origin in that state of the constitution which, for want of more accurate knowledge, we call the strumous diathesis. Hence it has happened that the attention of English surgeons has been directed in an especial manner to the subject of articular diseases. Many and various are the opinions which have been held, and the plans of treatment which have been advocated. While some have recommended the least possible amount of interference, others have boasted of the benefits to be derived from capital operations; and it seems that we are only now approaching the time when we shall be in a position to adjudicate upon the merits of these rival systems.

The present is an opportune moment for the publication of a work upon joint diseases. Any surgeon who, like Mr. Holmes Coote, can look back over a period of twenty-five years spent in practice, must have heard several totally distinct plans of treatment discussed, and must have seen different methods of practice tried. He must have had opportunities of contrasting the depletory and the tonic systems; he must have seen what can be done by simple rest, what by mechanical appliances, and what by operations; and if he can give us a sound opinion upon these various plans of treatment, and can help us to arrive at a just estimate of their respective value, he will have done something to advance the cause of scientific surgery in one of its most important branches.

Now, we think Mr. Coote may fairly claim to have done this, and we look upon his work as a valuable contribution to our modern professional literature. Besides being surgeon to one of our largest metropolitan hospitals, he has had special opportunities of studying the diseases of joints at the National Orthopaedic Hospital, and he has given us an excellent résumé of his experience in the volume before us. The excision

of diseased joints is a practice which has been on its trial for a sufficient length of time to allow us to form an estimate of its value; and assuredly the advocates of such operations cannot complain that they have not had a fair hearing. But while some surgeons have been testing the value of excisions, others have been trying what can be done, even in the most severe cases, by rest and the use of mechanical appliances; and our author, from the long experience which he has had both at a general hospital and also at one specially devoted to the treatment of deformities, has had unusual opportunities of forming an opinion upon the merits of these two plans of treatment.

It is, therefore, with no small interest that we have read Mr.

Holmes Coote's book; for we cannot help thinking that it serves to show in what direction professional opinion is moving in regard to the treatment of joint diseases, and what is likely to be the prevailing practice for some time to come. preface our author says "I have viewed with regret a somewhat growing inclination for the early performance of operations, particularly resections; and, much as I admire the spirit of conservatism with which that proceeding is characterised, as opposed to amputation, yet must confess a misgiving as to its general applicability, and feel a desire that the advantages to be derived from mechanical treatment and the enforcement of complete rest should be tried more continuously and with yet greater patience." This opinion is one which we are inclined to think has been gaining ground rapidly of late, and which will probably be endorsed by a large number of his professional brethren.

In the very outset of his work, when dealing with the classification of joint diseases, our author makes some remarks which give us an insight into the large and philosophical view that he takes of his subject:

"In most works on 'diseases of joints,' we read of inflammations, whether acute, subacute, or chronic, as occurring in the synovial membrane, cartilage, bone, or ligament; and this comprises the whole, or nearly so, of the pathological conditions. With this classification I find fault. In the first place, it omits all mention of deformities, whether congenital or acquired; it does not touch upon changes dependent on errors of nutrition; and it assumes the existence of inflammation in some tissues, such as cartilage, where such disease never occurs; or in others, such as ligament, where its presence is only secondary, and dependent on inflammation spreading from other sources."-P. 3.

Here, then, we see that Mr. Holmes Coote is determined to depart from the beaten track of previous observers, and that he is led to do so in conformity with the most advanced views of modern pathology. A short time ago, all the diseases of joints were held to be of an inflammatory character. They were all supposed to have their origin in inflammation affecting one tissue or another. But now we recognise various morbid alterations which are not preceded by a state of inflammation; and we believe that such conclusions are the result of that searching and discriminating investigation which characterises the pathology of the present day.

Our author includes, too, in his treatise, the deformities as well as the diseases of the joints. We are glad to see that such is the case; for there is no sufficient reason why a work upon

the diseases of the joints should deal with their acute condition only, and stop short of their ultimate results, which are ofte just as difficult and troublesome to treat. Indeed, the chroni diseases of joints are so tedious, that the general hospitals ca seldom afford to admit them, and hence they have almost be come a special branch of practice. But there is no sufficien reason why this should be the case. It is in the highest degre desirable that all students should see the lamentable result which, after the lapse of a few years, frequently follow th acute diseases of joints, and that all surgeons should be able to treat these chronic affections. We are glad, therefore, to fin that our author has included within the scope of his wor both classes of joint diseases—both the acute which are treate at our general hospitals, and also the chronic ones, which hav hitherto, in too many cases, been handed over to the depart ment of orthopaedic surgery.

Mr. Holmes Coote very justly points out that the rules which guide our practice in public institutions ought not to be differen from those which we follow in our private practice. "Surgeon in public practice should not despond of success, nor fly at a early date to so serious a measure as amputation or the resec tion of a joint, because the parts do not speedily become sound We dare not act so in private practice." (P. 6.) And then h goes on to say, "One object of this work is to call attention t the natural processes of repair, to point out how much may b done, even in the most unpromising cases, by combining mecha nical with general treatment, and the strict enforcement o rest." (P. 6.) These are principles which are coëxtensive with th field of surgery; they do not belong to any one department and there is no reason why surgeons should not avail themselve more generally of the various appliances which experience ha shown to be useful in these cases.

The author's remarks upon simple atrophy and hypertroph of cartilage are not without their interest. The non-inflamma tory morbid conditions of joints, the changes which are depen dent upon alterations of nutrition, are subjects which have onl recently been investigated, and of which our knowledge is stil far from being complete. The paragraphs upon this subjec in the volume before us will be read with interest and profit Passing on from the simple nutritive changes which take plac in cartilage, Mr. Holmes Coote proceeds to discuss at som length the pathology of the so-called ulceration of that struc ture; and he shows that the treatment by rest and gentle mea sures is that which is most in conformity with the true natur of the case. The practice of forcibly setting a limb in its righ position is one which our author condemns in strong terms, an

he points out how seldom it can be employed with advantage. Certainly, if we reflect upon the anatomy of the joints, and consider that they fall into the flexed position as being that which gives the patient the most ease and comfort, we cannot expect to alter their direction without inflicting severe injury upon parts which are often in a highly sensitive state, if not in a condition of active disease. We believe, as a general rule, that rough and forcible methods of treatment are almost always unscientific, because they are opposed to those slow and gradual processes by which nature effects alterations, and, in many cases, completes cures.

On the vexed question of excision of the knee-joint, the opinion of such a man as Mr. Holmes Coote can hardly fail to be interesting to our readers. "I am no strong advocate," he says, "for the operation of resection of the knee-joint under any circumstances, and disapprove of it almost unconditionally in children, in whom the limb afterwards becomes year by year weaker, more withered, and less equal to the opposite member." Our author then proceeds to give the history of a case which has fallen under his notice, and perhaps our readers will pardon us if we quote it at length. The interest of the subject must be our excuse if it seems rather a long extract.

"On February 14th, 1863, one of my colleagues amputated, at St. Bartholomew's Hospital, the left thigh of a boy, æt. 12, who had undergone the operation of excision of the knee-joint in another hospital, in consequence of scrofulous disease of the articulation, about nine months previously. The condition of the boy before the second operation was as follows:-He was not much emaciated, nor had his face lost all trace of the usual florid colour. The left lower extremity was an inch and a half shorter than the opposite; the thigh was hot and swelled; sinuses led from the incisions about the knee to dead or denuded bone. There was some mobility at the knee, the limb was utterly useless, and the opinion was general that the sooner it was removed by amputation the better. Upon making the usual incisions, it was found that the tissues were much infiltrated, and some considerable sinuses extended upwards among the muscles of the thigh.

"The hæmorrhage was troublesome, in consequence of the generally increased vascularity of the limb. The examination of the amputated parts, including the seat of the resection, was full of interest. In the first place, very little of the bony surfaces of the tibia and femur had been cut away at the time of the resection; their usual outline remained: therefore, although the epiphyses had been left, arrest of development was still a consequence of the operations. Secondly, the greater part of the synovial membrane was left behind in a thickened, discoloured, and pulpy state, keeping up the effects of disease in full activity. Thirdly, there were numerous scrofulous