amazement proved to be an arm-presentation of many hours' standing, (the hand and fore-arm were extruded beyond the os externum,) which the individual who wished to impose it upon me, had made himself cognisant of, but had deserted without attempting to remedy. Disgusted with the very deliberateness of his purpose, I felt that from neglect the prospect for the poor sufferer was most unfavourable, and yet that I could not take one step in the case without assuming the serious responsibility of its issue. I waited half an hour in anxious hesitation, and then sent peremptorily for the practitioner who had placed me in this painful predicament. He had completed the delivery in which he had been engaged, and left the house. I sent again and again to his residence, and wherever he was thought likely to be found, insisting on his immediate presence. Another hour elapsed ere he thought proper to appear, when I gave up my unfortunate charge into his hands and withdrew. The woman died that evening undelivered.

Upon another occasion, I was sent for to the wife of the master of a canal-boat, which had just arrived in the docks at two o'clock P.M. Here, too, the hand, etc., had appeared beyond the os externum as early as four o'clock that morning; but, being plying on the canal, no assistance had been sought till now. I sat, it was impossible at any time to stand erect in a space scarcely five feet in height, and only about six feet by four in its whole extent between the opposite berths, -till nine o'clock at night, seven hours of the most wearying toil, both to mind and body, that I ever underwent. I succeeded in turning, the child being dead; and the boat was dragged ten miles further on its course the same night. I afterwards ascertained that the mother had a protracted struggle for recovery, of several months; that she never became strong, and died within two years, of disease believed to be the consequence of her hard labour on that occasion.

Other two cases, in which, as already stated, I had endeavoured to return the arm, but without success, ended more fortunately, delivery being accomplished by turning.

Dr. John Burns, in his work on Midwifery,' says: "When the hand and arm have been protruded, and the shoulder forced down in the vagina, it has been the practice with many, before attempting to turn, to return the arm again within the uterus; and when this was impracticable, it has been torn, or cut off, especially if the child were supposed to be dead; but children have been born alive in this mutilated state. . . . By the means pointed out, we may in almost every instance succeed in delivering the child. But it must be acknowledged, that in some cases, from neglect, or mismanagement, the woman is brought into great danger, or may even be allowed to die undelivered. This catastrophe proceeds sometimes from mere exhaustion, or from inflammation, but oftener, I apprehend, from rupture of the uterus; or, in a neglected case, so much irritation may be given to the system, as well as to the parts concerned in presentation, that although the delivery be easily accomplished, the woman does not recover, but dies either from pulmonic or abdominal inflammation, or fever, or flooding. Moreover, such tedious cases generally end unfavourably for the child."

Ninth edition, p. 421.

2 Ibid., p. 422.

Again Dr. Burns states: "When turning has not been practicable, if the child were supposed to be alive, the os uteri has been cut, or the Cæsarean operation has been proposed and practised." (In support, he refers to M. Baudelocque's Memoir in Recueil Period. tom. v, table i, cases 5 and 12.) "If dead, it has been extracted by pulling down the breech with a crotchet," (Peu, Pratique, p. 412; Smellie, 1722, col. xxxv, case 3; Giffard, 1725, case 3,) "and sometimes, in order to assist delivery, the body has been mutilated." (Perfect, vol. i, p. 351; Dr. J. Hamilton's cases, p. 104, who found it necessary to separate three of the vertebræ. Dr. Clarke, who twisted off the arm, and perforated the thorax freely (Med. and Phys. Jour. vol. viii, p. 394,)" or the head opened with a perforator. This ought always to be done when, on the one hand, the presentation cannot be raised to admit of turning, and on the other, there is no appearance of the process named spontaneous evolution taking place.'

The present case is so singular in its new and successful mode of treatment, that I can find no allusion to anything similar in obstetrical works, and therefore feel somewhat staggered by the solitariness of my impressions of its true nature. Head-version, it is true, or the grasping of the child's head in utero by the hand of the accoucheur, was the recognised practice in arm-presentations down to the time of Ambrose Parè, who was among the first, if not the first, to discover and recommend the superior advantages of foot-version. But the former operation, which, one would judge, must have indispensably required access of the operator's hand to the child's head, ere the membranes were ruptured, bears no resemblance to the modus operandi pursued on this occasion.

Was it a case (as a friend prudently suggested) merely of the hand descending with the head? Certainly not; I have met with such a combination repeatedly, which never caused any trouble, but cannot assimilate it in any degree with the presentation in question. Here, the hand was not accompanied by the head, but associated (when first discovered) with the acromial portion of the left shoulder, which, with the broad surface of the scapular region of same side, then formed the presentation. Besides, the hand and fore-arm did, subsequently, and many times, descend into the vagina, while the head (resting above the right ilium) could not be reached at all.

66

Is it inconceivable that the firm repressing power (much complained of by the woman, it may be remembered, as pushing back the child") persistently exerted for one hour and a quarter, primarily, above the elbow of the presenting arm, in the direction of the left ilium of the mother, and thus bearing, secondarily, upon the child's breech, which lay in the same direction, could-as it effected the progressive movement of the arm from the position in which it was first found, near to the mother's right ilium, on, and up, till it rested permanently opposite and partially beyond the left horizontal ramus of the pubesinduce the entire change of presentation? Is it inconceivable that such repressing power, steadily maintained, tertiarily, upon the corresponding parietes towards the fundus of the womb, could so relieve the opposite parietes, towards the lower or cervical portion, from the pressure of the foetal head, as to enable the muscular fibres of that portion to contract with greater vigour, and act an important part in

assisting to correct the mal-position, by wearing-to borrow a nautical phrase the head down to and into the pelvic cavity, simultaneously with the breech being urged upwards to the fundus? In answer to both questions, with extreme deference, I think not; and should another arm-presentation case ever come in my way, under suitable circumstances, I will desire to put in practice the very same course, modified only according to variety in position of the child, to be presently noticed, which I unqualifiedly believe has been successful in this occasion.

Two inquiries suggest themselves. 1. Would the same manipulations produce a like result, if the child's right arm presented, its face and abdomen corresponding with those of the mother, the head still resting upon, or above her right ilium? In that case, I should proceed in precisely the manner described, and hope for a similar termination. 2. Would the same management be applicable, if the longitudinal position of the child in utero were reversed from that in the instance related, the presentation being, then, the right or left arm, but with the head, whether occiput or sinciput, situated on, or above, the mother's left ilium, and the breech in the direction of her right ilium? Yes: but it would be necessary that the woman should lie upon her right side, and that the repressing force be employed by the right hand of the accoucheur.

Leeds, Sept. 10, 1852.

ON THE PATHOLOGY AND TREATMENT OF SOME
OBSCURE CASES OF LONG-CONTINUED
PAIN IN BONE.

By HENRY LEE, Esq., F.R.C.S., Surgeon to the Lock Hospital, etc.

The pain which attends suppuration in the interior of a bone, is not always in proportion to the pressure exercised by the confined fluid. It arises, apparently, in some cases from the tension produced in the condensed bone by the interstitial deposit of fresh bony matter. In other instances, a very small quantity of matter contained in soft spongy bone becomes a source of irritation, and appears to determine to, and fix in, the part some pain depending upon constitutional causes, `and which, were it not for the disease in the bone, might have fallen upon some other region. The morbid sensations once established will continue, although not originally produced by the local disease, until that is removed; and even after it has been removed they will, as if from confirmed habit, shew a tendency to return to their accustomed place. After a time, however, if the cause which has determined the pain to a particular spot be removed, and no fresh source of irritation be present, the symptoms will cease. The piece of bone from which the accompanying wood-cut is taken, was removed from the tibia of a person of highly nervous temperament, who had for years suffered most severe local pain, and been subject to a great variety of treatment under different medical men. At length the operation of tre

phining the tibia was performed by Sir B. Brodie. The pain did not immediately cease, but after an interval the patient permanently re

Fig. 5. Portion of thickened but soft bone, removed from a lower extremity of tibia,
shewing the cavity of a small abscess.

covered. The drawing (for which I am indebted to the kindness of Mr. Charles Hawkins) shows how small the cavity was in which the fluid was contained, and the soft and spongy nature of the bone in its immediate neighbourhood.

The following case appears to show, that a constitutional affection produced by syphilis or mercury, may in like manner be determined to, and localised in, a particular bone; and that the symptoms may there be kept up for almost an unlimited time by a very small quantity of matter in its interior.

CASE III. A married woman, of a light complexion, and twenty-four years of age, was admitted an out-patient at King's College Hospital in the year 1849. The left knee-joint was at that time enlarged and painful, a puffy elastic swelling presented itself on the outer side of the joint, affording somewhat the appearance of a dislocation of the patella: very little fluctuation could be detected within the synovial membrane. The whole of the surrounding parts were painful, but the pain appeared to be of a very different character, and much more severe when the weight of the body rested upon the affected limb, or when the knee-joint was bent. The principal suffering was, however, experienced at night, and especially after she had become warm in bed. The deep-seated "pain in the bone", would then entirely prevent her from sleeping. This condition had lasted, in a greater or less degree, for a year before she applied to King's College Hospital. Three years previous to this she had been treated for syphilis, and had taken mercury several times.

The joint was directed to be kept at rest, and three or four grains of the iodide of potassium were given three times a day. Under this treatment the swelling soon subsided, and the pain was much relieved. The joint could now be freely examined, and it became evident that the head of the tibia was the principal seat of the disease. Being relieved of her symptoms, the patient now discontinued her attendance, but remained free from pain for a short time only, when she again applied at the hospital: a repetition of the former treatment was again followed by complete relief. As soon as she discontinued her medicine, however, the symptoms returned. In this way she continued under treatment for three years, and at one time persevered with the iodide of potassium for six months without any material intermission. As long as she took the medicine she was easy, but upon discontinuing it the pain invariably recurred.

Being tired out by the long continuance of the disease, she now

The cases of trephining the tibia are in continuation of those previously given

wished, if possible, that something more should be done, and I mentioned to her that permanent relief might possibly be afforded by trephining the head of the tibia, where, as I conceived, some local cause was keeping up the disease. The patient, who before had refused to go into the hospital, now readily consented, for the purpose of having the operation performed. On her admission, the left leg, round the head of the tibia, measured half an inch in circumference more than the right. There was comparatively little pain or swelling, as she had been taking her medicine for some days; but she complained of tenderness upon pressure about the insertion of the ligamentum patellæ, and over the upper part of the internal tuberosity of the tibia, which was evidently enlarged. As the shaft of the bone was in no way affected, and the pain and swelling were confined to the immediate neighbourhood of the joint, it appeared that the epiphysis of the bone had originally been the seat of the disease. It became, therefore, necessary to apply the trephine to this part, taking care, at the same time, to avoid injuring the articulation. I had the advantage of Mr. Fergusson's and Mr. Partridge's advice; the operation was performed with their concurrence.

On the 29th of May, a T-shaped incision having been made over the upper part of the internal tuberosity of the tibia, the parts below were carefully separated with the handle of the scalpel, until the bone was felt with the point of the finger. The trephine, which was made purposely, with a very deep blade, and not more than a third of an inch in diameter, was now applied. As soon as the outer shell of bone was perforated, the cancellous structure was felt to give way under the pressure of the instrument, and some minute and separate flakes of white matter were observed to escape with the blood by its side. After the operation, water dressing was applied, and an opiate ordered at night. On the first of June, the patient stated that her leg had not felt so easy for four years. She had slept well every night since the operation, and was free from pain. There was no fever.

On the 4th the knee felt stiff and sore, and rather uncomfortable, but she had had no return of the "old pain"; a gutta percha splint was placed behind the joint.

5th. She was again free from pain.

7th. There was now, for the first time, some return of what she distinguished as the old pain.

12th. All uneasiness had now subsided without any medicine, and she felt quite comfortable.

18th. Had again some discomfort about the knee, but no further return of the former pain. The puffy swelling on the outer side of the tibia, which had in a great measure subsided, now increased, and became painful upon pressure; a diseased gland in the neck at the same time began to enlarge. She was ordered some citrate of iron in combination with the small doses of the iodide of potassium, and was directed to get up, as it was supposed that her present symptoms depended in a great measure upon her confinement to bed. In a week after this time she was enabled to leave the hospital, when her general appearance rapidly improved.

On the 24th of August her health was quite restored; she could raise her leg without any pain or inconvenience, and had experienced no return of the "old pain" since leaving the hospital.