1 Dr Bright, Medico-Chir. Transactions, 1833.

Mr Marston, Glasgow Medical Journal, cited in Edinburgh Monthly Medical Journal, January 1854.

NOTE-A case of fatty discharge has been published by Dr Eisenman in the Prague Vierteljahrschrift. In consequence of an error, I have not been able to obtain this work in time to complete the paper, which, with this exception, and a case in a Spanish journal, the notes of which I have mislaid, contains all, I believe, that has been published on the subject.

MR SPENCE'S SURGICAL CASES.

ARTICLE II.-Surgical Cases, with Remarks. By JAMES SPENCE,
Fellow of the Royal College of Surgeons, and Lecturer on
Surgery, Edinburgh.

I HAVE Selected the following from cases occurring in my practice,
principally as they seem to me to illustrate some points in surgical
pathology, and to possess interest in a practical point of view :-

CASE I.—Osteo-sarcoma of Forearm; Amputation; Recovery.

I was requested by Dr Cruickshank of North Berwick, to visit with him, Elizabeth Watt, residing at Williamston, who was affected with a large tumour of the forearm.

About eight years previously she had first observed a small firm swelling a little above the wrist, which continued to increase gradually and slowly, without much pain or inconvenience. About four years prior to my seeing her she had become alarmed about the tumour, and applied to Dr Cruickshank, The swelling at that time was who recognised the disease as osteo-sarcoma. about the size of an egg, limited distinctly to the lower end of the ulna, and had begun to interfere with the motions of the forearm and wrist. Dr Cruickshank advised her to submit to amputation at the middle of the forearm ; but the patient and her friends would not listen to the proposal, and applied for assistance to other practitioners. A variety of remedies, both general and local, seem to have been used, but without any good result. At last she fell into the hands of a bone doctor, and, as far as can be judged from her description of the treatment, he seems to have applied first a strong tincture of iodine, and ultimately some form of escharotic to the tumour, which gave rise to ulceration at one point, and still more rapid increase of volume, profuse discharge, pain, and great constitutional disturbance. She returned home, the tumour having attained an enormous size, and her general health completely undermined by the hectic induced by the profuse discharge and pain. Dr Cruickshank now saw her again, and he found her anxious to submit to any operation to obtain relief.

At my first visit she was lying in bed with the enormous solid tumour supported on a pillow it felt of the consistence of bone, with here and there softer points, the superficial veins were enormously enlarged, the fingers were firmly clenched, and the nails were elongated and curved like claws. A large, deep, ulcerated cavity in the tumour displayed portions of its osseous substance partly dead, and mixed with unhealthy discharge, and emitting a most insupportable fetor. Her general appearance indicated an extreme degree of debility: she was excessively emaciated, with sunk, anxious features, small, rapid pulse, etc. On examining the axilla, I found decided enlargement of one or two glands.

The extremely debilitated condition of the patient, together with the enlarged glands in the axilla, and the rapid growth latterly of the tumour, taken in connection with her cachectic look, seemed to militate against amputation; but, on the other hand, the originally simple character of the tumour, its slow progress up to the time of being irritated by stimulating applications, and its still retaining a solid osteo-sarcomatous appearance, together with the consideration that the mere irritation produced by the ulcerated portion was sufficient to cause enlargement of the axillary glands, and that its removal, though only as a temporary alleviation of her suffering, would be a boon to the patient, made me decide on amputating. Dr Cruickshank having put the patient under chloroform, I removed the arm by double flap a little below the insertion of the deltoid. There was great venous hemorrhage in making the incisions, and the blood flowed in a stream from the veins of the tumour, even after the bone was sawn through.

NEW SERIES.-NO. LI. MARCHI 1854.

?E

Six or seven arteries required ligature. After the patient was put in bed she was excessively weak, but gradually revived. An opiate was ordered to be given after the effects of the chloroform had passed off.

I visited her again on the fourth day after the amputation. The stump was looking well, and her general appearance much improved. Her pulse was under 90, and she had slept well ever since the operation. I continued to see her from time to time. The greater part of the stump was soon firmly healed. About the tenth day a large abscess formed in the axilla and over the pectoral muscle; this was opened, and, as it was diffuse, a counter opening was made in the arm. Under careful treatment she continued to improve, and was soon able to get up and go out.

I saw her in September 1853 in excellent health, and examined the stump and axilla carefully. There was not the slightest trace of any tendency to reproduction of the disease, and she still continues in perfect health.

The tumour, when removed, was found to weigh eight pounds and a half; its length was fourteen inches, its greatest circumference, corresponding to about the middle of the forearm, was eighteen inches, immediately above the wrist sixteen inches, and near the elbow twelve inches. It consisted almost entirely of osseous matter, with an admixture of soft fibro-cartilaginous-looking deposit. The great vessels and nerves of the forearm, together with the muscles and tendons, passed into and through the tumour, or formed grooves for themselves, more or less deep, as represented in the accompanying plate. The diseased growth seemed limited at each extremity by the articular cartilage; but, although commencing distinctly in the ulna, the disease had progressed laterally so as to blend the shafts of the ulna and radius inseparably into one general mass. Neither the humerus superiorly nor the carpus inferiorly were implicated, but the cartilage of incrustation of the bones of the forearm was partially absorbed. The veins on the surface of the tumour were of enormous size, as seen during its dissection.

Remarks. The foregoing case, independently of the enormous size of the tumour, has interest in a practical point of view in reference to the pathology of similar growths. 1st. The slow progress in development whilst left alone, compared with the rapid increase in volume when the use of deobstruent remedies were had recourse to in the vain hope of discussing the tumour. During the four years which the tumour had existed prior to her showing it to Dr Cruickshank it had only attained the size of an egg, and it was some time after he had recommended its removal by operation that the patient applied for advice to others, and commenced the use of remedies to promote its discussion. Yet, under such treatment, it increased to the enormous size it ultimately attained in a shorter period than it took to reach the comparatively small size of an egg when left to its own natural progress. The period, however, from which the constitution became affected was after the application of the escharotic which had caused the ulceration of the tumour.

This can be readily accounted for by the local irritation produced by the ulceration of the opened out texture of the osseous tumour, the necrosis of portions of it which took place, and the profuse discharge consequent on these conditions. The history of the case in this respect may serve to enforce the good practical rule that in cases of tumours where removal by operation is objected to by the patient or deemed inexpedient, the safest plan is to refrain from meddlesome treatment.