to make an accurate examination of his case, and felt satisfied of the propriety of operating on him.

My patient is of healthy constitution, nervous temperament, rather slender make, with the expression of muscular weakness, of small size of body, with great disproportion between the trunk and lower extremities, the latter being much shorter in consequence of the contracted state of the muscles in the groins, knee, and foot joints. Hoeke measures, supported by his crutches, only four feet six inches. The columna spinalis is perfectly straight in the erect position without any deviation to either side, but its lower part forms a curvature outwardly while sitting, which disappears when standing. The pelvis and the bony portions of the lower and upper extremities are perfectly natural. The muscular system is weak and not much developed, presenting more the rounded form of the female than the fulness of the male. Having never been used to muscular exercise, he has contracted very lazy habits. There is an abnormal mobility of the joints of his fingers, which he is able to bend backwards, owing to relaxation of the ligaments of the joints. His intellectual faculties are undisturbed, the organs of sensation unimpaired, the susceptibility of the nervous system rather increased. There is no morbid affection in the thorax and abdomen except the disposition to piles, in consequence, as it appears, of want of exercise. The spinal marrow and its coverings (ligamentous as well as osseous) do not present any morbid condition, so far as a careful examination enables me to decide. The muscles of the lower extremities are lax and without vigour, the glutei thin and rigid. Both thighs are of the same thickness. The left femur is kept constantly crossed over the right, and cannot be removed out of this position by the patient, either while standing or sitting, or by manual means. The sartorius, gracilis, and adductor longus muscle, with the fascia lata femoris, are very much contracted and rigid, which can be best observed by placing the finger on the inner side of each groin. Every attempt at removing the left femur from the right, bringing both on a level and separating them, causes great pain in the groin and lower part of the back, and produces involuntary jerkings and cramps of the extremities, while the thick cord-like contracted adductor longus muscle can be felt on both sides of the groin very resisting. In consequence of this muscular contraction (in which the pelvic muscles also appear to participate), the femora are kept permanently bent on the pelvis, and the thighs cannot be extended. The external abdominal muscles are likewise contracted, imparting to the finger the feeling of a board. The patient is able to move the left femur at the hip joint in a slight degree, but not the right, which after having remained for many years behind the other, does not allow of any motion at the hip joint, but is permanently flexed on the pelvis. The left femur can be extended by mechanical means, but not the right, the muscular contraction in the groin being the strongest. The patient never lies on his back, but on either side, with the knees drawn up.

The bones of the knee joint are perfect and natural, the muscular contraction is very strong. The joints are kept bent at a right angle. The muscles in the ham appear like cords on each side of the joint, the patella is raised and does not admit of the slightest motion. Both knee joints are inverted, the right one the most, representing the form which is occasionally met with in blacksmiths. The patient is not able to bend the knee joints, but does so with his hands, the left knee allowing of a greater degree of flexion than the right. When an attempt is made to extend the knee joints, there is great pain felt in the sartorius, gracilis, semitendinosus, semimembranosus, and in both capita of the biceps femoris, which appear like tense cords. In consequence of the unusual retraction of the patella, the natural form of the knee joint appears to be somewhat altered and flattened.

The muscles of the legs are wasted, the left more than the right, owing to the compression of the left arteria poplitea, in consequence of the crossed position of the femora, and nutrition being thereby impeded.

There is no deviation from the natural standard of sensibility and of temperature in the extremities.

The feet present a fair specimen of pes valgus of the older writers, which Scoutetten, in his admirable memoir on club-foot, calls very properly everted club-foot. The grastrocnemii muscles are shortened by contraction more than two inches, and the inner side of the sole only and the tips of the toes touch the ground. The musculi peronei are also contracted, in consequence of which the external side of the foot is raised and the foot itself everted. The soles of the feet are entirely level, without the natural hollow on the inside, and the internal ankles are more prominent than usual.

His way of progression, by throwing forwards both extremities at a time, while supported by crutches, is extremely tedious, tiresome and distressing. My patient was subject to spasms and involuntary jerkings of his extremities from his childhood, which have rather increased in frequency, but not in intensity, for the last six years, and have obliged him to keep his feet very warm. If this was neglected, spasms afflicted him oftener and more violently. The jerkings of his limbs, from which the left suffers more than the right, make their appearance on the least noise or slightest excitement. A careful examination of this interesting case proved that muscular contraction caused this pitiable deformity, and that an operation, although extensive, would restore the patient to the use of his limbs; and encouraged by the success which attended my operations on stiff and contracted knees, wry-neck, and every variety of deformed feet, I expressed to my patient an opinion with regard to the probability of success, and found him willing to undergo any treatment for the slightest hope of relief.

Without entering into a theoretical discussion, whether the deformity was congenital or acquired by disease, whether there was any organic or functional lesion of the nervous centres, their investments or of the peripherical nerves, to which could be attributed the subsequent contraction of the limbs ; whether there was a chronic irritation of the muscles of the extremities which caused the pathological change, or a morbid innervation of the extensor and abductor muscles-the propriety of an operation could not be denied, inasmuch as muscular power, though impaired for want of exercise, and entire sensibility existed in the deformed limbs. There was no disproportion between the lower and upper part of his body, except that caused by the contraction of the limbs. It appeared to me that though he would not be able to walk without crutches after his limbs were straightened, yet in course of time and by frequent exercise, muscular power night develope itself more fully, and crutches could be gradually dispensed with. Even under the supposition, that he never would gain sufficient strength to walk without any support, feelings of humanity and commiseration induced me to operate on him for the restoration of his members, while on the other side an operation skilfully performed could not do him the least harm.

I felt convinced that the spastic movements of his extremities, having their origin in some morbid affection of the nervous system, would continue after the operation, but this should not be urged as a reason to give up an operation intended to remove such a distressing deformity. It might also be objected that the continuance of the spasms would again cause contraction. This, however, I deny, since they are slight and only accidental, and since the deformity has not increased during the last six years.

Without any preparation of the organismus for enduring the traumatic infliction (which I consider unnecessary in this kind of operations), I operated on him on September 19th, 1839, kindly assisted by Drs. J. P. Gazzam and G. D. Bruce, of this city. Being aware that a good many muscles and tendons had to be divided in a nervous and irritable constitution, and apprehending some traumatic reaction, I intended to operate first on one extremity, and after some time on the other. But after having severed all contracted muscles in the groin, ham, and at the heel on one side, my patient, endowed with great courage and resolution, wanted the other also to be operated on,

which was done at the same time, with the loss of only a few drops of blood. The severing of the muscles did not inflict on him much pain, but the feeling of the tendons being cut through, and separating with a violent and audible crack, was disagreeable.

For the division of the adductors, I placed my patient in the horizontal position across the edge of a bed, and after the thighs had been forcibly abducted as far as possible by the assistant surgeons, I introduced a slightly concave narrow knife (such as I use for operating on club-feet, but longer and stronger,) one inch below Poupart's ligament, and one inch and a half from the inner side of the femur, the femoral artery and vein being on the outer side, parallel with, and along the external side of the adductor longus muscle, and feeling with my finger its point on the back part of the thigh, turned the edge of the knife towards the median line of the body, and severed by repeated sections the attachment of the adductor longus and gracilis muscle along with the fascia lata covering it, by carrying the point of the knife along the inner surface of the skin in order to ensure a complete section of the muscles. This being done with a forcible and audible crack on the left femur, while the hollow between the cut surfaces could distinctly be felt for an inch, the femur could be easily separated and abducted. The same operation was performed on the right femur with the same result, the knees being separated for about nine inches. The incisions of the skin did not exceed in length the eighth part of an inch. Only a few drops of blood escaped from the orifices.

I then made the patient turn on his face, and after the knee-joint had been extended as far as possible, and the ham strings made tense, I grasped the biceps femoris muscle between two fingers of the left hand, and introduced the knife one inch above the poples on the external side of the kneejoint through the skin, and severed this muscle; at the same distance above the poples on the inner side of the knee-joint, I cut the tendons of the sartorius, gracilis, semimembranosus, and semitendinosus. A very audible crack followed the section of each of them, and the knee immediately allow

of complete extension. The same operation was done on the other knee. It is to be remarked that the gracilis muscle was cut at both points of its insertion, and that reunion nevertheless took place.

To remedy the deformity of the feet, both tendines achillis were cut across by entering the knife on one side of the leg. But so strong and rigid was this tendon, and so sudden and powerful the retraction after its section, that only the greatest care prevented the knife from passing through the skin behind the tendon. I consider it absolutely necessary, to restore perfectly the pes valgus, to divide the peronei muscles which cause while contracted the eversion of the foot and the tilting up of its outer side. Below the malleoli externi, both these muscles were severed in each foot, which I never found difficult to divide at this point, although Scoutetten, in his memoir on club-foot, objects to it, preferring their section above the malleolus. The whole operation, comprising the division of ten muscles and tendons by five incisions of the skin on each extremity, did not occupy more than two minutes, and was done without bleeding or inflicting much pain on the patient. Amongst nearly sixty patients upon whom I have operated in this city, I have never before met with such a rigid condition of the tendons and such a powerful retraction of the muscles.

Graduated compresses with the usual bandaging were applied, and in case pain should supervene, cold applications were ordered. Extension was not made, the limbs being kept in the same position as before the operation,

At my night visit, I was not a little surprised to see my patient quite comfortable, sitting in bed, talking and enjoying the smoke of his pipe. There was not the least febrile excitement, and no pain in the cut muscles, or any uneasiness, except a slight degree of spasm in the lower extremities, particularly in the left. Indeed, I had expected some febrile reaction after the

section of many muscles, though I never yet saw any thing like fever and active inflammation after the cutting of tendons, in all the cases I have operated on (comprehending patients from a few days old to 35 years of age.) To prevent the spastic movements of his extremities, acetate of morph. gr. 4, was ordered at bed time, and cold applications continued to the incisions.

The next day he felt quite well, had enjoyed a good night's rest, without any fever, but with spastic movements of the extremities, causing pain in the cut muscles. Morph. acetat. gr. 4, three times a day was continued, as also the antiphlogistic regimen; cold applications discontinued.

Forty-eight hours after the operation, the spastic contractions had subsided, the small incisions were healed, there was not any swelling about them, nor any inflammation. I commenced to-day extending the contracted extremities in an apparatus similar to that of Strohmeyer. To the leg piece I had attached a thigh board with a joint, on each side of which an apparatus was fixed for the purpose of bringing both pieces (the leg and thigh boards) gradually straight. Each extremity being placed in a machine and secured by straps and bandages, a kind of machinery was affixed to each thigh board, for the purpose of separating the thighs gradually, which could now be kept seven inches apart, between the knees, without any pain. I kept my patient on a mattress on his back, with his shoulders slightly elevated.

On the third day after the operation, a very annoying diarrhoea supervened, consisting of a mucous discharge from the lower part of the bowels with tenesmus. The spastic contractions of the limbs reappeared in a slight degree, particularly in the left. I went on extending the knees, heels, and separating the femora. There was greater tightness in the left groin, but not any pain in the back, of which he had complained before the operation on every attempt to separate his limbs.

Every day I extended the limbs more, my patient rested pretty well, though he did not like the recumbent position, and the spasmodic contractions continued in a slight degree. But the mucous diarrhoea mixed with blood caused by the appearance of hæmorrhoidal tumours, external as well as internal, continued troublesome, and did not yield readily to medication. After seven days extension, the knees were separated a foot, and the distance between both heels, two feet. The knee joints were nearly straight, and the heels on a level with the toes, and the outer side of the foot with the inner. After each extension the patient felt a degree of tightness and uneasiness in the stretched muscles for about an hour or an hour and a half, but this wore off and left him comfortable with the exception of spasms. But tired of the recumbent position, and wetted by the frequent discharge from the bowels, and being badly attended by his friends, he insisted on the removal of the apparatus. We, however, remonstrated against it, and continued the extension for some days longer, when we had the satisfaction of seeing his knees separated sixteen inches, his knee-joints perfectly straight without any inclination of the knees inwards, and the heels on a level with the toes. We would have kept on the extending apparatus some time longer, but were obliged to remove them at the expiration of two weeks after the operation, from the appearance of a sore on the os sacrum, and of commencing soreness of the skin of his feet and knees, although we had taken every care and precaution to avoid it. With the appearance of sores he suffered much from spasms and jerkings, and his rest was disturbed. But all went on favourably as soon as the bandages were removed.

To prevent contraction of the extended muscles, we used splints and bandages, and placed some cushions between his knees.

It ought to be mentioned that Hoeke was, during health, subject to spasms, and that they were aggravated during the time of extension, by the occurrence of sores. So great indeed was the excitability of his nervous system, that the least touch with a finger on his limbs excited the spasms, which were more severe towards evening than during night or in the morning.

The mucous and bloody diarrhoea with the hemorrhoidal tumours disappeared at the end of three weeks, when he commenced to sit up in bed and on a chair. The soreness of his feet did not yet allow him to use them, although he could stand supported by crutches, and use his limbs as if walking. The spasms gradually decreased, although the habitual jerkings remained.

There did not appear any disposition in the severed muscles to contract again, his extremities being perfectly straight in every respect, and his stature increased six inches. For nearly ten weeks we had to attend to the sores, and three months after the operation was performed he used his extremities more, felt them growing stronger every day, and is now walking about on his crutches, although yet weak. He has the complete use of his legs, can bend and extend them, performs abduction and adduction of the femora with the greatest ease, and there is not the least inclination of the left knee to cross the right. He can stand straight without any support, can now walk with one crutch, but prefers to use both from the fear of falling. It is rather remarkable, that the jerkings and cramps in his limbs have decreased very much, as well in intensity as in frequency.

My very esteemed friends Drs. J. P. Gazzam and G. D. Bruce saw my patient while walking sometime ago, and were struck with the success of the operation.

I might appear to be too sanguine in expressing the hope that my patient may, in the course of years, so far recover as to be able to walk without any support, which he never did since he was born; but from the history of his case I am inclined to believe that locomotion was out of the question as long as the contraction of the muscles existed, which was observable in the first years of his life, and that the want of exercise in consequence of the contracted muscles produced the weakness of his limbs; though I do not feel disposed to deny that some derangement of the nervous system, although unknown to us, either originating in the medulla spinalis and propagated from thence to the peripherical nerves, or in the peripherical nerves, and reflected to the nervous centres, may be a link in the chain of morbid phenomena causing innervation of the muscles. I leave the latter supposition, which is difficult of resolution, and proves that much yet remains unknown as to the etiology of deformities, to the theoretical speculator, and content myself with remarking, that if this man was in better circumstances, allowing of the administration of every means calculated to increase bodily strength, I have not the least doubt, that for the pains and trouble I took with him, I should be amply rewarded by the satisfaction of seeing him walking with comfort and ease, and without any support.

Should, however, this fortunate result not take place, and his strength never increase to the degree necessary to support his body, I believe I have been of much service to him-in having remedied a very distressing and pitiable deformity, and restored to him the use of his limbs-as well as, I hope, to the profession, by communicating the successful result of a new and interesting operation, which has never been equalled in the number of tendons and muscles divided.

For the American Medical Intelligencer.

ART. II.-CASE OF HEMIPLEGIA PRESUMED TO BE DEPENDENT UPON GASTRIC DERANGEMENT.

BY THOS. H. collier, m. d.

New Church, Accomack county, Va, April 9, 1840.

A lady, æt. 20, was attacked with common bilious fever, pain in the back and extremities; slight chill at the commencement of the disease; continued