EXCISION OF THE GREATER PORTION OF THE ULNA. thickened, and peeled easily off the bone. I therefore carried my incision a little higher up, until it appeared perfectly healthy. The next step was to divide the bone. This I attempted to do with a pair of Liston's bone forceps, having first made a notch in the bone with a small saw; unfortunately however in my attempt, one of the blades of the forceps gave way. I had immediate recourse to one of Hey's crown saws, which was at hand, an assistant holding down the flaps; the bone was with some difficulty sawn through. The next step was to disarticulate the bone at the wrist; this there was little difficulty in doing. An incision was carried down from the lower end of the ulcer in a direct line with that made up the arm to the head of the metacarpal bone of the little finger, the tendons of the flexor and extensor muscles being carefully separated from their attachments on the anterior and posterior aspect. The knife was then thrust perpendicularly betwixt the radius and ulna, and carried round the articulating surface, completely dividing the sacciform ligament, and the attachments of the triangular fibro-cartilage. There was now little left but the attachments of the interosseous ligament. A copper spatula having been passed under the disarticulated end of the bone, by gently raising it there was more freedom allowed for carefully dissecting the piece out, which was done without wounding any large artery; one small vessel only was divided, a branch from the interosseal, but the hæmorrhage from it was so trifling as not to require ligature. Several portions of very thickened periosteum were dissected out of the bottom of the wound. The edges of the incision at the wrist were brought together with adhesive plaster. As there was reason to suppose from the tolerably healthy state of parts that union would take place by the first intention, the upper portion of the wound was filled up with dry lint. The patient was then put to bed with his arm pronated, and resting upon a high pillow, and cold water dressing applied. He bore the operation very well; little more than three ounces of blood were lost. 8. p.m. on the day of operation. Has been tolerably easy, and slept at intervals in the afternoon, rather thirsty, pulse 80. To have fifty drops of laudanum immediately. March 16th, 10 a.m. Has slept between three and four hours in the early part of the night, and has been dosing this morning. Does not complain of pain in the arm; pulse 90, regular, rather full; face a little flushed; tongue moist, and a little furred in the centre, which has been so for some months. No thirst; bowels not open. To have tea and bread and butter, Arrowroot if he wants it. Continue wet cloths. 8 p.m. Has been easy during the day; no great pain in the arm, no swelling; pulse 100; slept none; bowels not open ; is cheerful, and in good spirits. To have fifty drops of tincture of opium in the night if he does not sleep, and cold spirit lotion applied. 17th, 10 p.m. Last night about half-past ten, he complained of griping pain in his bowels; the draught was administered, which procured him immediate relief, and a good night's rest, having slept six hours. Pulse 100, but regular and sharp. Heat of skin natural; no great thirst; bowels not open; does not complain of much pain in the arm; no swelling; 351 8 p.m. Has had his bowels opened twice with the castor oil; arm easy; has slept two hours in the afternoon; was a little chilly when he awoke. Pulse 102, and sharp. To have forty-five drops of tincture of opium in the night, if he does not sleep. 18th. He took the draught in the night, and slept nearly eight hours. Perspired a little in the morning. Pulse 100. The dressings were for the first time removed; a considerable quantity of pus followed; wound looks healthy; no hæmorrhage. Dressed with dry lint as before, brought round with a few strips of plaster. 8 p.m. Has slept two hours in the afternoon; arm easy. To have fifty drops of tincture of opium at bed time. March 19th. Has had a good night, and feels very comfortable. No swelling or uneasiness in the arm. Pulse 100. Perspired freely in the night; dressing removed; no hæmorrhage; wound looks healthy, and granulations springing up around the edge of the old ulcer. Dressed with dry lint, 20th. Has not had a good night, having been without his draught; bowels open; dressing removed; free discharge of pus of a healthy character; here and there slight union had taken place betwixt the lips of the wound, these were broken up in order to allow of the free escape of matter. To be dressed with dry lint as before, and covered over with soap plaster. 25th. Sleeps well; no perspirations; wound looks very healthy; no uneasiness in the arm. To have meat diet, and a pint of porter daily. 26th. Sleeps well; bowels open; tongue clean and moist; no perspirations; wound at the wrist nearly healed. There is a little discharge from the end of the bone, which appears more prominent than usual, but has plenty of covering. The arm was freely extended, which gave him no pain. 27th. Only feels a little stiff. The arm can be put in a state of pronation or supination without any uneasiness. The arm to be placed in the same semiflex position, but a little more extended. Continue his meat diet, and porter. 28th. Pulse 84; slept well; has had some pain along the front part of the arm, from the altered posiTo be strapped as tion and movement yesterday. before, but without any lint, and the arm to be more flexed. April 1. Wound looks healthy; complains of pain at the end of the bone. Got up to-day for several hours, sleeps well, and takes his food well. 4th. Bottom of the wound filling up, and very much contracted. The edges of the old ulcer appear irritable and painful. To have them touched with the nitrate of silver; can pronate and supinate the hand 352 EXCISION OF THE GREATER PORTION OF THE ULNA. himself. The fingers are rather stiff. The incision at the wrist perfectly healed. Health very good. 7th. Wound continues improving; the edges of the old ulcer still painful, but look more healthy. Nitrate of silver applied to them. Has perspired a little the last two nights. Complains a little of sore throat; is a little feverish: bowels open. To steam his throat with hot water frequently. 9th. Sore throat better; the edges of the ulcer appear irritable; the discharge is unhealthy, and the ulceration is extending over the skin in the under surface of the arm. To have it fomented frequently with warm water, and linseed poultice applied for a few days. 12th. Since the poultice has been applied, the wound has discharged freely. The edges of the ulcer look clean and more healthy. Poultice to be discontinued, and the would strapped as before. 14th. Ulcer healing rapidly. Surface very much contracted, and new skin forming. Says he feels in better health. 20th. Has been walking out daily since last report, and came down to the surgery to have it dressed with plaster. The granulations are now nearly on a level with the edges of the wound, which has to day an irritable and erysipelatous appearance, brought on, I imagine, from some injudicious friend giving him wine. To have a poultice applied, and to take some aperient mixture. From this period the edges and parts around the old ulcer alternately progressed and retrograded. During the whole progress of the case the pus secreted from the ulcer was very similar to what is seen in opening a scrofulous abscess of the neck. Until the beginning of June, a variety of topical applications were used without much benefit. Amongst these I may mention solutions of sulphate of zinc, sulphate of copper, black wash, and the nitrate of silver in pencil, with a view of altering the character of the sore, attention at the same time being directed to the digestive functions, with generous diet; strapping with soap plaister, and bandaging the arm, were found on the whole most efficacious. The incisions made with the knife being at this time healed, he was sent to the sea side, and ordered to bathe the arm in salt water. There he remained five weeks, and returned with the sore quite healed, and in perfect health. REMARKS. I think it is pretty evident from the early history of the case, that the bone had received serious injury, and although he was able to follow his employment for some time after the accident, no doubt there was a considerable degree of inflammation of the bone and periosteum going on. We are well aware that bone generally speaking is very slow in taking on diseased action, but there was here, besides the injury, a scrofulous diathesis to combat with, which merely required some external agency to produce its development. We see too, how in such a constitution diseased action may suspend itself, and attack a more distant organ, and after a time return to the seat of the original mischief. With regard to the operation, I may remark that the difficulty attending the division of the bone was, inde pendent of its enlargement, much increased, owing to the blade of the forceps giving way, and though it would have materially shortened the operation, I much question if I could have accomplished my object with them. I found Hey's saws answer every purpose, though tedious in their operation; the only danger likely to accrue from their use, is when having nearly divided the whole thickness of bone, they might, if caution were not used, suddenly pass through and divide the ulnar artery which is lying close to it. It is better therefore to finish the division with the forceps. Velpeau had a case in which he was anxious to remove the radius for disease entirely restricted to that bone, but the patient would not submit to the operation, and had her arm amputated. In his book, (Nouv. Elem. de Med. Oper., Tome 1,) he recommends a chain saw to be placed under the bone, by means of a director, and the bone to be sawed through, and if there was not room for its use by the longitudinal incision, that a transverse one should be made. I have never used the chain saw, nor seen it used, though much has been written about its applicability in such cases, but I should much question the propriety of its use in any case. The removal of portions of the shafts and extremities of bones extending into joints, is now a matter of common occurrence, but the resection of the whole thickness of any of the long bones for necrosis is extremely rare. I am not aware that any case has presented itself, in this country at least, nor can I find any case on record in which so much bone has been removed. The disease, as you will perceive in the specimen before you, is extensive, and extends close to the articular extremity, and though the heads of long bones are slow in taking on diseased action, it would in this instance soon have been affected, and though the head of the bone is not anatomically connected with the wrist joint, there is every reason to fear that sooner or later the limb would have required amputation. You will be able to judge of the present appearance of the limb by this cast. The arm is small certainly, but the muscles, although wasted very much, have a very considerable degree of power, indeed the youth has been daily exercising it in rowing about on the river: he can pronate and supinate the hand, can flex and extend the fingers readily, and has free motion at INTRA-UTERINE TUMOUR. CASE OF INTRA-UTERINE TUMOUR. By T. OGIER Ward, M.D. TO THE EDITOR OF THE PROVINCIAL MEDICAL AND SIR, I beg leave to forward to you the enclosed communication, which I received last week, with the desire that it should be sent to you, And I remain, Sir, Your obedient servant, Birkenhead, August 6th, 1844. 353 and purging, I determined to explore the nature of the tumour with a small trocar, thinking, that if there were a fœtus or mole, it would be expelled, and thus only one life might be sacrificed, and if a cyst, it would be evacuated. The instrument seemed to pass into a firm substance, and upon withdrawing the trocar, about half a pint of rather gelatinous, brown fluid followed, when the canula became obstructed by a white greasy matter, resembling that which covers the bodies of new-born infants, and like that consisting of epithelial scales. The operation gave great relief to all the symptoms for a time, but they recurred in about ten days, with their former obstinacy, though not with equal violence. She then became an inmate of the poor-house, and died at the end of March. Her body was examined, and the gentlemen who presided gave me the following account: Having read in the Provincial Journal of yesterday your case of Intra-uterine Tumour, I venture to send you an imperfect history of a somewhat similar case that I have met with, in the hope that, by comparing-There were only slight vestiges remaining of the left notes, we may be enabled to throw some light upon the nature and origin of these formations. In February last I was requested to see a poor woman, aged 45, who was said to be dying, when I found her suffering from violent and almost incessant purging and vomiting of a yellow feculent fluid, like thin gruel, in alternate attacks, recurring every two or three days. She was much wasted; complexion like a gipsy's, eyes staring, countenance anxious, tongue furred and dry, incessant thirst, pulse rapid and feeble. Besides the vomiting, she complained of intense pain over the whole abdomen, which was exquisitely tender to the touch. The lower part from the navel was occupied by a firm round tumour, without fluctuation, though rather elastic, and sounding dull on percussion. She told me she had been twice married; had one child by her first husband, and miscarried about six months before; since then she had been regular, till about three months ago, when she first perceived a small tumour in her left flank, which had gradually increased till it acquired its present size and place; and during this time her health had become impaired, though her present symptoms were only of three weeks continuance. There was some discrepancy between her account and that of her husband and neighbours respecting the first appearance of the tumour and her last menstrual period, for she seemed to have lost her recollection in a great degree, and was often delirious. On examina tion, per vaginam, I found the os uteri smooth, firm, and closed, projecting forwards into the vagina, as though the body were pressed down into the hollow of the sacrum, but there was no indication of the presence of any tumour in connexion with the uterus, nor did it give the idea that it was enlarged. The form of the tumour, its position, and the closure of the os uteri, | together with the recent miscarriage and cessation of the menses, induced an opinion that it might be a case of pregnancy, or hydatids, or serous cysts, while the woman's account of its origin, and the ideas of her husband and her friends rendered it more probable that it was ovarian disease; at the same time the extreme pain and tenderness, the vomiting and purging, with fever and delirium, led me to suspect it might be an acute affection of the peritoneum, though the altered complexion was indicative of cancer. Not being satisfied with any of these reasonings, and believing that if not relieved, she would die in a few days, as I found medicine had no power to arrest the vomiting ovary; the os uteri was quite scirrhous, but not ulcerated nor tuberculated. The uterine cavity was filled with a white steatomatous matter, containing a lock of hair. There was no appearance of a cyst, nor any fluid round it, and the uterine wall varied from 1-4th to 1-8th of an inch in thickness. The mass was as large as a child's head of a year old. The rectum adhered to the uterus, but there were no marks of peritoneal inflammation, nor any adhesion of the uterus to the abdominal parietes at the place where it had been punctured. I ought to add that the gentleman who conducted the inspection knew nothing of the history of the case previous to the admission of the patient into the poor-house. This case presents several points of interest, both physiological and practical. 1. I am not aware that any person has noticed that the white substance that covers new-born infants consists mainly of epithelial scales, mingled with a saponaceous matter; and it appears to me that if you can find them among the steatomatous mass described in your letter, it will go far to prove that they are not a product of the fatal epidermis, but a uterine secretion. This point you will easily ascertain by a com parison of the two, with the aid of a microscope of ordinary power. 2. It also establishes the fact, that the distended uterus may be punctured, and some of its contents withdrawn, not only without producing any expulsive efforts, but with decided relief to the symptoms arising from that distension; for, as there were no marks of peritoneal or other'inflammation, I cannot but consider that the tenderness, pain, vomiting, purging, and prostration, were sympathetic only of the uterine irritation, and that, not of the os tincæ, which, though scirrhous, was never prominently painful, but of the body of the womb. 3. The presence of a lock of hair proves that there must have been a nisus formativus in the first instance; and if we suppose that this produced-as is likelyincreased action in the uterus, the researches of Mr. Addison would in some degree support the notion, that the action of an effete uterus might be abnormal, and that a vast formation of epithelial scales instead of the ordinary membranes, might be the result; or, what is more propable perhaps, that the membranes enveloping the tuft of hair received no accession from the uterus, while the epithelial secretion was inordinately increased, and enveloped them in a thick mass. Ihave met with no case of uterine serous cysts since this case occurred, to be enabled to remark whether their surface exhibits epithelial scales. 4. The secretion of epithelium in this case must have been enormous, for all parties agreed that the tumour could not have been above five months in acquiring its size, when I first saw her. 5. The ages of both cases agree with that of most persons whom I have remarked with uterine serous cysts, which, like the present, I look upon as the last abortive efforts of the reproductive function previous to its perfect cessation. 6. The strongly marked symptoms of the last stage of peritoneal inflammation, before what used to be termed the stage of gangrene, might have induced me to use powerful antiphlogistic treatment, had I seen her before her strength became exhausted; and yet I should have committted a grievous error; and this, nowithstanding I tried to guard against mistake, by varying my mode of pressure, secundum artem, over the tumour and other parts of the abdomen. The chest was not tender. By the way, let me ask whether you find gangrene in all cases of fatal perito. nitis where the pain subsides before death? I must say I do not; and even after the operation for hernia, the gangrene is rarely very extensive where it exists at all, and never equally so as the attending inflammation. 7. The ileus alternating with colliquative diarrhoea, without local disease of the bowels, (if we except the two important meetings, which at this early period have already been held in different parts of the country. It is a fortunate circumstance that from the late introduction of the Bill into the House of Commons, it is impracticable that it should during this Session be carried through its several stages, so as to become a part of the law of the land. Time is thus allowed for a consideration of its provisions by the whole medical profession, and for the expression of opinion with regard to the merits or demerits of the leading points, and on the effective. The example of the Warwickshire and machinery by which it is intended to be rendered the Surrey practitioners will, we trust, be followed by the members of the profession resident in other counties, and in the larger and more populous towns, and it cannot be doubted but that the general agreement which we believe to exist amongst all classes of the profession, on certain parts of the measure, must have some effect. It is highly desirable that this, and indeed any measure on the subject, should be regarded in the twofold character of its relation to the public welfare, and its bearing on the interests of the medical profession. The profession have a right to expect that, as far as is consistent adhesions of the rectum to the uterus,) is also interest-with the former of these objects the public ing, particularly as neither symptom was relieved by any mode of treatment, except by the puncture and unloading of the uterus. I should not have thought my single case worth publishing, had not the similarity of yours, and the paper of Mr. Addison appearing in the same number of the Journal, induced me to think that if the examination of your preparation supports my views, this letter, enriched by your observations, may afford an interesting confirmation to the theoretic portion of Mr. Addison's valuable writings on the subject of nutrition. At all events I shall feel obliged by your forwarding it to Dr. Streeten, with or without any additions of your own; and for thus troubling you I must plead non omnia possumus omnes, and remain, Your obliged, T. OGIER WARD. welfare-their own views of the management of their own concerns should be at least considered and treated with respect. No extra-professional individual, however highly he may be otherwise qualified, is competent to judge of what is best and most fitting for the regulation of matters of which he is by education, or rather by want of education and due information, necessarily ignorant. We will even go farther, and say that no one professional person can of himself know what the wants of the whole profession require, and to follow or be guided solely by the opinion of London practitioners as to the state of medical practice, and the requirements of medical polity in the provinces, or of provincial practitioners as to the medical wants of metropolitan towns, must inevitably lead to error, and give rise to dissatisfaction. As far, therefore, as regards the internal regulation of its concerns, the whole medical profession, not one portion of it alone nor merely one or two selected individuals, ought to have been consulted and Medical & Surgical Journal. have a right to be heard. As far as the public wel WEDNESDAY, SEPTEMBER 4, 1844. fare is concerned,although the Government and the Legislature may possibly be, cæteris paribus, the best judges, yet do we think that true wisdom should lead those in power to listen to those who are better qualified to form an opinion in some points at least than themselves. The removal of restraints from empirical practice we believe to be more detrimental, to be fraught with more danger, to the public in general, than injurious to the interests of the medical profession. It is especially affairs of their several associated charities might be arranged, and thus the inconvenience of having to attend two separate meetings would be prevented. In reference to the suggestion of a grant from the tion towards our benevolent fund, we know that there funds of the Provincial Medical and Surgical Associaare already many of our members who do not subscribe either to the benevolent fund, or to local charities; if, however, the Association's funds were applied to the purposes of charity, would not this offer an excuse to these very men for still withhholding their individual support, inasmuch as they may consider, and justly too, that the Association's funds do in part belong to them; and further, that such funds have been subscribed for the express purpose of benefitting the subscribers, by furnishing to them the greatest possible amount of medical and surgical knowledge at the least possible expence, and that through the medium of a weekly journal and an annual volume of transactions? on account of the mischief which must result to the poorer classes and to children, that we are anxious to see some effective provision for the suppression of quackery, and for the prohibition of the administration of dangerous and powerful medicines by persons ignorant of their use. The uninformed amongst the wealthy may obtain information, if they are so disposed, and can at any rate take care of themselves, and if Members of Parliament, who are so ready to cheer the withdrawal of all check on the homicidal administration of medicine, are desirous of retaining the privilege of swallowing an indefinite quantity of Morison's pills or any other like nostrum, under the advice of a known empiric, by all means let them have it. Let it be made a privilege of Parliament, and replace the franking of letters if it so please them; but the public at large are entitled to receive Respecting Dr. Budd's amendment upon my motion, protection, though perhaps too ignorant to look for I may be allowed to regret that I had it not in my it, as well against the empiric in medicine, as against power to remain to the termination of the second the empiric in law,—from an illiterate and unautho-discusssion thereon is given in the Journal, I think that day's meeting; but as a pretty full account of the rized traffic in health and life, as well as from any my explanatory letter to Dr. Favell might also have other species of swindling; and it is precisely appeared. I trust, however, that the Committee apbecause they are ignorant, and helplessly ignorant, pointed may see it expedient to continue a weekly that such protection is required. publication, and that as there is a surplus fund, they may recommend its application for the purposes of the extension of medical and surgical science. I have the honour to remain, Sir, Your obedient Servant, JAMES INGLIS, LOCAL BENEVOLENT FUNDS. TO THE EDITOR OF THE PROVINCIAL MEDICAL AND SIR, May I be permitted, through your Journal, to offer a few remarks upon one or two of the subjects that came before the meeting at Northampton, and instead of answering, as I once thought of doing, when the meeting had passed over, Dr. Conolly's letter of the 19th of July, I would rather propose a suggestion, whereby we may all agree in furthering the object which, I am sure, we all desire to obtain, although perhaps by different means. At the meeting a very marked difference of opinion manifested itself regarding the comparative advantages of a general central fund, or, of a number of distinct local charities. Mr. Martin said, that in many counties there already existed medical benevolent societies; and Dr. Conolly replied that in many counties there were no such local charities, both of which statements were undoubtedly correct; but why should the latter statement remain longer a fact? Surely enough is known of the working of local charities to enable every district to have its own benevolent association; and although I must still consider that the Provincial Medical and Surgical Association would have greatly stepped out of its province by even attempting to form a compulsory benevolent fund, still I conceive that the council of this great body may be of much use, through its district branches, by suggesting to them the propriety of originating local charities in those counties where they do not at present exist; benevolent funds, which, like the present central fund, might be in connection with, although constitutionally distinct from, the Association. At, or after the branch meetings, the Halifax, August 16, 1844. SIR JAMES GRAHAM'S MEDICAL BILL. On Thursday, the 22nd of August, 1844, the medical practitioners of the county of Surrey assembled at the Coffee House at Epsom, for the purpose of taking into consideration "A Bill for the better regulation of medical practice throughout the united kingdom," which the Right Hon. the Secretary of State for the Home Department had lately presented to the House of Commons: THOMAS Martin, Esq., OF REIGATE, IN THE CHAIR. Whereupon, after mature deliberation, it was proposed by James Stedman, Esq., of Guilford, and seconded by William Chaldecott, Esq., of Dorking, and resolved unanimously, That this meeting views with disapprobation the proposed constitution of the "Council of Health, and Medical Education," as not being likely to possess the confidence of the profession. And that this meeting cannot refrain from expressing its surprise and regret, that no general practitioner is, by this bill, proposed to be appointed on the Council of Health and Medical Education. Thereby witholding from that most important and numerous body a voice in the council, from which it is proposed should emanate all the laws and regulations which will have so important, so vital, an effect, on the future condition of the great body of the medical practitioners throughout the united kingdom. |