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REPORT OF A CASE OF DISEASE OF THE HIP-JOINT, IN WHICH THE OPERATION OF EXCISION OF THE UPPER END OF THE FEMUR WAS PERFORMED.
579 that the risk of this untoward event is not greater in traumatic than in idiopathic cases. The next point is, how far the tying an artery at a distance from the wound is justifiable as a means of arresting haemorrhage. Mr. Guthrie lays it down healthy pus, the ligature has not yet come away, but the as an unexceptionable rule, that "all wounded arteries are to wound is almost healed; appetite very good; general health be treated by ligatures of the artery at the wounded part." He says, also, in his introductory lecture, " If surgeons fly for improving. On the 21st of August, being three weeks after the opera- assistance to Mr. Hunter’s theory for the cure of diseased tion, the ligature came away; the man still in good condition; arteries they will find a method of proceeding which is never successful when put in practice for a wounded artery, or at no signs of union of the bones, but healthy suppuration. so seldom successful as to form only an exception to the On the 28th, a large abscess formed on the outer part of the leg, above the seat of fracture, which caused him great pain, general principle already mentioned, and which can never and on being opened, discharged a considerable quantity of be departed from without imminent danger to the limb, if not pus; from this time the discharge continued very great, the to the life of the patient." This is strong language; and in venturing the opinion that man’s appetite still good, takes tonics and stimuli freely. About ten days after this, vomiting came on, and strength there are cases which should form an exception to this rules began to fail; an abscess also formed in the calf, which dis- such, namely, as those I have just related,-I am aware that I may incur the imputation of presumption in questioning so charged very freely. On the 18th of September, being about fifty days from the gigantic an authority as Mr. Guthrie; but then I cannot forget time the artery was tied, haemorrhage came on again, and the that I am supported by some great names, and amongst others, leg was immediately amputated; the case has since progressed by one of the first surgeons of modern times, one who "being favourably, and the stump is healing. On examining the dead, yet speaketh"-the much to be lamented Liston. He limb after its removal, two large detached portions of bone states, " that cases may occur in which it is both more convenient and more scientific to apply a ligature at a distance were found in the abscess; one from the tibia, and the other from the fibula, so that the accident was originally a commi- from a wounded artery;" and it appears to me, that the cases nuted as well as a compound fracture-a circumstance which, I have related fully bear out this opinion. I do not for a mohad it been known, would have been a strong argument in ment deny, that immediately upon the receipt of injury, if a favour of amputation in the first instance; it was difficult to large vessel be wounded, it is best to secure the divided ends. trace exactly the wound in the artery, but my investigations I do not, in fact, argue against the correctness of this principle left but little doubt on my mind that it was the posterior so strongly laid down by Mr. Guthrie; it is rather against the tibial. These three cases appear to me to illustrate some universality of its application that I am contending. I believe the parts have become covered with granulainteresting points of surgery, respecting which authorities that wherever Mr. Guthrie, in his highly tions, so as to conceal the bleeding point, and to cause the are not perfectly agreed. practical lectures on the treatment of wounds, and injuries structures to break away under the forceps and the ligature, of arteries, puts forth as a strong argument against tying - wherever, again, there is a sloughy and inflamed condition of the surrounding parts, so as to obscure the position of the an artery at a distance from the seat of injury, the imminent and the patient is so enfeebled by previous loss of blood, danger thereby incurred of inducing sloughing of the parts. vessel, He says," If the femoral artery be punctured near the groin, that any additional flow may prove fatal; wherever, lastly, and a diffused aneurism form in a few days, can the operation there is a compound fracture attended with uncontrollable of placing a ligature on the external iliac be performed on arterial haemorrhage, but in other respects presenting a fair the same principle, and with the same hope of success, as if prospect of recovery ;-under these three several conditions of the case had been one of true aneurism of several weeks or parts, any endeavour to find the wounded vessel is attended months’ durationThe answer is in the negative. The Hun- with great difficulty, and will most probably end in failure, terian theory of aneurism is not applicable to this case. The involving the loss of the limb, and perhaps the life, of the surgeon, who placed a ligature on the external iliac under patient; and that, under all these circumstances, the easiest, such circumstances, would probably lose his patient from mor- the safest, the most effectual, and therefore the most scientific tification, because the collateral branches would not yet have plan, is to pass a ligature round the main artery where the had time to enlarge." parts are in a healthy and unaltered condition. (I may menI must acknowledge I am very sceptical as to the correct- tion, that since I read this paper, a clinical lecture by M. ness of the data upon which this reasoning is founded. I do Baudens has been published in THE LANCET, upon this subject. not believe that in ordinary cases of aneurism the circulation He says: " In those cases where compression has been kept up through the sac is so far impeded or diminished as to cause unsuccessfully for so long a time that the artery has inflamed, enlargement of the collateral vessels, a condition of parts it is advisable to apply but one ligature on the cardiac end of which Mr. Guthrie seems to think so important as affording the vessel, but high enough to meet with healthy structures." the chief ground of hope for the vitality of the limb after a Here then is another valuable testimony in favour of the plan ligature has been placed on the main artery; a condition, also, I am advocating.) The non-recurrence of haemorrhage in those cases which I which, if it really existed, would contra-indicate the operation of tying the vessel, as it would show that Nature was ac- have related is at least an encouragement to adopt a similar complishing a cure spontaneously; but even admitting, for plan under like circumstances; for the bleeding which took the sake of argument, that the fact is correct, it does not place in the third case, coming on fifty days after the ligature appear to me that the inference drawn from it is quite legi- was applied, shows that if the restorative process had not been timate. prevented by a foreign body, the operation would have accomIn the cases I have just related, the main artery of both plished the desired object. upper and lower extremities are tied, and not only is there no threatening of mortification, but scarcely any appreciable REPORT OF A diminution of temperature, and the restorative action goes on at least as favourably as before the operation, and as rapidly CASE OF DISEASE OF THE HIP-JOINT, as usual. These cases, then, as far as they go, clearly tell IN WHICH THE OPERATION OF EXCISION OF THE UPPER END OF against Mr. Guthrie’s statement on this subject. THE FEMUR WAS PERFORMED. Dupuytren, Gumbaud, Samuel Cooper, Bransby Cooper, HENRY BY SMITH, M.R.C.S. Eng., Liston, and others, have all related cases in which success FORMERLY HOUSE-SURGEON TO KING’S COLLEGE HOSPITAL. has attended the tying vessels at a distance from the wounded part; but these Mr. Guthrie states were by chance and not on principle; this, of course, may also be applied to the cases I IN the beginning of May I was requested by Dr. Gavin have just read, but when three instances occur in succession, Milroy to see William R-, aged thirty-three, living in in which the circulation is rapidly and completely re- Drury-lane, and who had been labouring for some time under established, one begins to suspect, in spite of the very high disease of the hip, by which he had become completely authority brought into question, that something more than crippled. The following is the history of the case previous to chance is involved here, and that Nature often possesses the his coming under my care. Seventeen months ago, he first felt a pain of a gnawing power of at once establishing the circulation through a limb after the main artery is tied, without the existence of an character in the left hip-joint; this was preceded by an attack aneurism, or of any of the preliminary preparation insisted of lumbago. At first, the pain was felt only at night, and upon by Mr. Guthrie. It is far from my intention, in these when the joint was moved; he did not suffer while working at remarks, to underrate the danger of mortification after tying his trade, (that of a shoemaker.) He continued in this state the main artery of a limb; my object is merely to suggest for some five or six months, during which time he was re-
the second day after the operation is: limb warm, and feels comfortable; there has been no more haemorrhage; healthy discharge from the wound. A fortnight after this, the report is: the wound discharges
port on
least
.
580 medical advice. Medicines were given to him, and effect this with more ease, a small incision at right angles witl counter-irritants were applied to the hip, but no benefit the first, was made. The limb was then carried across the accrued; and he was then admitted into one of the largest other, and by this means, and the fingers of the assistant, the hospitals in the metropolis, and placed under the care of a very upper end of the bone was thrust out of the wound as much eminent surgeon. After he had been in the hospital two as possible. The knife was then carried carefully round belo-vi months, an issue was made over the joint, and kept open for the great trochanter, and with a common saw the section oj three months. At the end of this time pain left the hip, ex. the bone was made. The condition of the acetabulum was cept when he moved; but this cessation from suffering only then looked to, and a portion of the rim being found carious, continued for a short time, after which the joint began to the bone forceps were used there; the gouge was also applied swell, and pus formed, which was evacuated by the surgeon. to a small bare spot at the bottom of the cavity. The wound The patient thinks that the thigh-bone slipped from its socket was then stitched together, and water-dressing was applied, about three months after his admission into the hospital, as No vessel required a ligature. There were not more than four he gradually became unable to lie upon his right side from ounces of blood lost. The portion of bone removed measured that time, and was obliged, by degrees, to take to the position a little more than three inches in length, the section having he is now in-viz., on his back. been made just below the great trochanter. The disease was He was told that nothing more could be done for him, and wholly confined to the articulating surface, which was entirely was consequently discharged from the hospital, and taken to denuded of its cartilage, and carious; some imperfect granulahis own home, for the purpose of being sent to the workhouse. tions existed over some portion of it. Since maceration the In company with Dr. Milroy, I carefully examined the bone has presented a most beautiful and perfect specimen of patient, and found him in the following condition:-Lying on caries. his back, with the left thigh thrown across the other, and One hour after the operation, the patient appeared in a comsupported by a pillow. There is considerable fulness about fortable state; he remembered nothing about it. Complained the hip, and just below the trochanter is an opening, dis- of some pain in the wound, from which a slight oozing of blood charging a thin purulent fluid. There is shortening of the existed. Pulse 84. To have nothing but a little thin gruel limb of about an inch, and by laying hold of the lower part of and cold water. Eleven P .III.: He has been dozing a good deal the femur, and rotating it, the head of the bone can be dis- since the operation; feels pretty comfortable; oozing from the tinctly felt on the dorsum ilii, and it is evident that no anky- wound has stopped; pulse 104. June 15th.-I was delighted, when I entered his room, to losis or attempt at such has taken place. By introducing a probe through the above-mentioned opening, it can be carried see this patient doing so well. There has been no shock at in various directions, but particularly over the head of the bone; all; he has passed a comfortable night; febrile action modeby the most strict examination, however, no bare bone can be rate ; tongue slightly furred; pulse 120, very feeble; comdiscovered. He complains of great pain when the limb is plains of thirst; wound looking healthy; takes nothing but moved, and when pressure is made over the head of the femur. gruel and barley-water. I dressed the wound with warm There is no fulness in the iliac region, no tenderness there, water. and nothing amiss in the lumbar spine. The man, who has 16th.-Has passed a good night; complains of very little been a fine, tall fellow, is much wasted, has become very pain in the wound,which is now beginning to discharge matter of a healthy character; no immoderate swelling about the weak, perspires at night, and has a rapid and feeble pulse. After carefully looking at this case, I expressed my opinion wound; pulse 110, and somewhat fuller; has taken a little to Dr. Milroy, that it was one of those in which the surgeon mutton broth to-day, which he relished. 18th.-Yesterday there was a little tenseness about the might take into consideration the propriety of some operative proceeding,-of an exploratory character, at least,-and then wound, but to-day this has disappeared, and he is doing adact according to circumstances. It appeared to me, that the mirably ; sleeps well; eats an egg night and morning; granuhead of the bone was the part principally affected; and that, lations of a healthy character are appearing in the wound; dislying as it did in its abnormal situation, it was acting as the charge from it moderate, and of a bland appearance; pulse 98. source of irritation, and was gradually destroying the patient. 20th.-Still rapidly improving: his bowels (which had been It was evident that there was no disease of a very serious well cleared of their contents previously to the operation, in nature in the pelvis. Taking this into consideration, and to order that he should not be necessitated to change his position. what an extremity the patient was reduced, I did not hesitate while the wound was in a fresh state) have not been moved to regard this case as one for which the operation of excision since; and he is to take a table-spoonful of castor-oil. Granuof the head of the femur was adapted. It was determined, lation of the wound going on rapidly. To have half-a-pint of however, that we should be in no hurry about the operation, ’ beer daily. 21st.-In consequence of the rather severe operation of the but would watch the patient and examine him carefully from time to time. physic, he has not been so well. Pulse 84: more feeble. HeI Subsequently to this, my friend Mr. Walton, and Messrs. complains of pain below the wound, and on looking there, Arnott and Shaw, severally saw the case, and agreed with me find a slight blush, and swelling of the part-but the wound in the opinion I expressed of the nature of the disease, and in itself is looking remarkably healthy. I ordered the uneasy the propriety of making some exploration of the parts with part to be well fomented, and the patient to take a small porthe knife. Before resorting to any measure, I determined to tion of solid meat. have the benefit of Mr. Fergusson’s experience. That gentle23rd.-Doing well; he complains no longer of the pain man kindly visited the patient with me, and after a careful below the wound, and the inflammatory blush has subsided; examination, expressed his conviction that it was one of those his appetite is good; tongue clean; discharge of a very healthy cases in which the surgeon ought to interfere, as the disease character, and moderate in quantity. 27th.-Since last report, this patient has been progressing appeared to be limited chiefly to the head of the femur, and the patient had no chance of recovery from any natural or most favourably; he is beginning to feel stronger; appetite remedial measures. good; pulse under 100, and fuller; the wound has healed up As the patient was living in a small, confined room, with to a great extent; the discharge is still abundant, but partiseveral children about him, I had him removed to the neigh- cularly healthy. He still perspires at night; he takes meat bouring house of one of his relatives, where he could get and beer daily. I ordered the following-Sulphate of quinine better air and more attention, and it was determined that the one grain; diluted sulphuric acid, twenty minims; water, an operation should be performed after he had remained quiet ounce. Mix for a draught, three times a day. for a few days in his new lodging. In the meantime, Dr. Mil29th.-The wound has now so nearly healed up, that I thisroy carefully examined the condition of his health, and the day placed the limb (which since the operation has been state of the patient’s lungs, and found nothing in those respects lying somewhat in the same situation as it was before the, to contra-indicate an operation. Accordingly, on the 14th of operation, with a much contracted knee) upon a Liston splint; June, I excised the head of the femur, in the presence of Pro- and got it into a much better position, intending daily to exfessors Fergusson and Partridge, Messrs. Arnott, Walton, tend it. This operation gave the patient considerable pain, and caused the wound to bleed somewhat. Bowman, Ure, Shute, Nunn, Bishop, &c. July 8th.-Since the last report he has not been doing soOperation.-The patient having been placed under the influence of chloroform by Dr. Snow, and laid on a table on his well ; he complained much of the operation of placing the right side, I commenced an incision over the head of the bone, limb on the splint; and lie has been suffering as much constiand carried it to the extent of about seven inches in the direc- tutional disturbance as he did after the original operation. tion of the shaft of the femur. By this the head of the femur There has evidently been caused a fresh attack of inflammawas exposed, and it was discovered lying in the midst of an tion in the part, as indicated by profuse suppuration, and a abscess, and in a carious condition. The tissues were then partial re-opening of the wound, and tenseness and swelling cleared away from the neck and trochanter, and in order to about the hip. The tongue had been furred, pulse quickened.
ceiving
581
making any way. Now, however, yet very incomplete; nor do they frequently take much pains this disturbance has ceased; tongue is clean; appetite good; afterwards to improve it. Their advancement has not been the wound looks very healthy, and the discharge is moderate, sufficient to induce them to pursue such studies as a source of and of a good character. He still perspires at night. The mental enjoyment; and their time is frequently occupied in a limb has been daily extended, and it is now much straighter. manner notvery favourable to a literary taste. The conTo have two glasses of wine daily. sequence is, that the scanty knowledge with which they left 14th.-Progressing favourably. The wound has contracted, school becomes daily diminished in degree, until at the end of and healed much, and the discharge comes only from one or their apprenticeship it has dwindled into utter insignificance. In this place it is impossible to avoid adverting to the pretwo small places. The limb is now very nearly straight. valent system of apprenticeship as required by the Society All the functions of the body are well performed. 22nd.-He has, during the last few days, had an attack of of Apothecaries. We scarcely know in what sufficiently diarrhoea, attended with griping, which has pulled him down strong terms to express our sense of the impolicy and pernicious tendency of these apprenticeships, as an integral part a bit; but this was checked by regulating his diet, and the The limb has become so straight, of professional education. We do not mean to deny that use of aromatic confection. and the wound so far healed, that I have taken the splint off, some useful knowledge is obtained in the course of their and laid the leg on a pillow. There is still a considerable duration; but, generally speaking, it might be gained on much amount of discharge, of a healthy character, however. He easier terms by a different arrangement, while much that is has for the last few days complained of pain on the outside pernicious in habits of idleness, and too frequently of moral of the thigh, a few inches below the wound, where there is a depravity, might in a great degree be avoided. In almost blush of inflammation, and a feeling as though matter were every instance, we believe, the five years of apprenticeship, taken from that period of life when the mind is most capable forming. I ordered it to be well fomented. August 2nd.-Nearly all swelling has gone down. There has of useful training and of profitable application to study, might been a free and healthy suppuration, which now, however, is be disposed of in a manner incalculably more beneficial-in but slight. The wound is looking in a most healthy condition,the acquisition of the classical and mathematical knowledge to the length of an inch and a half. The already referred to as so indispensable, and of various other and has patient is ableto move the thigh somewhat, and is gradually branches of general acquirement calculated to develop the regaining his strength. He eats and sleeps well, and com- mental powers, and prepare them for the subsequent duties plains of no pain. He has been taking, for the last few days,, of life, social and moral, as well as professional. a mixture of iron and quinine. But it may be asked, Ought not the student in medicine to 28th.-Since the last report the patient has been gradually have a knowledge of pharmaceutical preparations !-Ought he progressing, and he is altogether in as favourable a condition not to be familiarized with the various substances employed in the relief of disease-with their appearances, their mechaas could be expected. The wound has nearly healed up. A considerable discharge has been kept up from the various nical, chemical, and remedial qualities-their doses, modes of sinuses which existed prior to the removal of the head of the preparation, and of exhibition or application ? Without bone, and which necessarily take a long time in closing. doubt, all this ought to be the case; but much of it cannot There were some indications of matter down the thigh some be learned at all, or at least but very imperfectly, during an few days ago, consequently I made a deep counter-opening a apprenticeship, and the rest might be as conveniently acfew inches below the wound, but without evacuating any pus. quired without it. But besides all this, many prejudices and The movement of the limb is much more free; and I have false notions are frequently imbibed in relation to the nature every reason to suppose that a new joint has already partially and objects of the profession, which are with difficulty, if at formed. The general health is satisfactory; the appetite all, subsequently laid aside, and give an unfavourable colourgood. The night-sweats have left him. The pulse has become ing to the future progress of education. These facts connected with medical apprenticeships are full, and moderate in frequency, and the man is slowly revery generally acknowledged; but still it is thought that they gaining flesh. cannot be dispensed with, as a necessary means of enabling Caroline-street, Bedford-square, November, 1848. the practitioner to conduct his business, particularly the (To be continued.) pharmaceutical part of it. This places the subject in a totally different point of view. Let it once be admitted that apprenticeships are intended, not for the instruction of the pupil9 AN ESSAY ON MEDICAL REFORM; but for the cmavenience of the practitioner, and we may feel. WITH SUGGESTIONS FOR THE RE-ORGANIZATION OF THE MEDICAL assured that the system is tottering to its fall. It is simply PROFESSION. one of pecuniary profit; and surely this ought not to be placed BY THOS. MICHAEL GREENHOW, ESQ., F.R.C.S., &c., in competition with the intellectual and moral welfare of the Newcastle-on-Tyne, student, and his future proficiency in professional knowledge. SURGEON TO THE NEWCASTLE INFIRMARY AND EYE INFIRMARY. It is doubtless convenient for the practitioner to procure persons to prepare his prescriptions without pecuniary charge, "Sed longe alia est ars medica, et longe aliis difficultatibus implicita." but nevertheless he might obtain more competent assistants for this purpose, were he denied the opportunity of taking (Concluded from p. 402.) apprentices. [WANT of space precludes our publishing the whole of Mr. It is clearly required of the enlightened physician, to know Greenhow’s observations, but in the following abstract we all that can be known by the most skilful surgeon; nor is it present our readers with the main points which he desires to less essential to the latter, to possess all the knowledge of the most accomplished physician. What then follows ?1 If all urge on the attention of the profession.]-ED. L. the members of the profession are thus required to pursue After having given a brief history of the medical corpora- a definite and comprehensive course of study, and to give tions, the author proceeds thus :public proofs of equal proficiency, they are surely entitled to We shall not enter into any detail of the curriculum of receive equal honours, and one general designation. As professional study which every student should be required to regards titles, privileges, and qualifications, all distinctions, pass through; it ought to include every branch of natural therefore, ought to be abolished. This may be called a science that can in any degree bear upon an enlightened com- levelling plan, a term which is not generally received with prehension of the nature, causes, and cure of disease, and it much favour, but if it be a levelling plan, it is one of an ought to be ample as to time. It is of little consequence that unobjectionable character; its purpose is not to bring down a highly-gifted mind here and there may be enabled to acquire the hills to the same plane with the valleys, but to raise the a full share of knowledge in a shorter space of time, and withlatter to the altitude of the former, that all may begin their out pursuing that systematic course of study which is abso- career in life, so far as legislative arrangements are concerned, lutely necessary for the complete instruction of ordinary minds. with the same opportunities of gaining professional knowLegislation must have reference to the many, and not to the few; ledge, and the same, or at least a high degree of actual attainand the regulations which it lays down must be of a general, ment. But here the equality ceases; a thousand circumnot of a partial character. It will, we think, scarcely be denied stances, personal and adventitious, will soon establish distincby any one acquainted with the ordinary attainments of youths tions, not in legal privileges, but in public estimation, in who enter themselves as medical students, that their pre- professional reputation, and, by consequence, in pecuniary paratory education has, in a large majority of cases, been emolument. But if equal qualifications are to be required from all the very imperfect. They are generally bound apprentices between their fifteenth and sixteenth years, when their know- candidates for professional honours, and all are to be designated ledge of classical literature and of mathematical science isi by one common title, it is evident that all must have their
and he felt he has not been
I
contracted
.
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"
the second day after the operation is: limb warm, and feels comfortable; there has been no more haemorrhage; healthy discharge from the wound. A fortnight after this, the report is: the wound discharges
port on
least
.
580 medical advice. Medicines were given to him, and effect this with more ease, a small incision at right angles witl counter-irritants were applied to the hip, but no benefit the first, was made. The limb was then carried across the accrued; and he was then admitted into one of the largest other, and by this means, and the fingers of the assistant, the hospitals in the metropolis, and placed under the care of a very upper end of the bone was thrust out of the wound as much eminent surgeon. After he had been in the hospital two as possible. The knife was then carried carefully round belo-vi months, an issue was made over the joint, and kept open for the great trochanter, and with a common saw the section oj three months. At the end of this time pain left the hip, ex. the bone was made. The condition of the acetabulum was cept when he moved; but this cessation from suffering only then looked to, and a portion of the rim being found carious, continued for a short time, after which the joint began to the bone forceps were used there; the gouge was also applied swell, and pus formed, which was evacuated by the surgeon. to a small bare spot at the bottom of the cavity. The wound The patient thinks that the thigh-bone slipped from its socket was then stitched together, and water-dressing was applied, about three months after his admission into the hospital, as No vessel required a ligature. There were not more than four he gradually became unable to lie upon his right side from ounces of blood lost. The portion of bone removed measured that time, and was obliged, by degrees, to take to the position a little more than three inches in length, the section having he is now in-viz., on his back. been made just below the great trochanter. The disease was He was told that nothing more could be done for him, and wholly confined to the articulating surface, which was entirely was consequently discharged from the hospital, and taken to denuded of its cartilage, and carious; some imperfect granulahis own home, for the purpose of being sent to the workhouse. tions existed over some portion of it. Since maceration the In company with Dr. Milroy, I carefully examined the bone has presented a most beautiful and perfect specimen of patient, and found him in the following condition:-Lying on caries. his back, with the left thigh thrown across the other, and One hour after the operation, the patient appeared in a comsupported by a pillow. There is considerable fulness about fortable state; he remembered nothing about it. Complained the hip, and just below the trochanter is an opening, dis- of some pain in the wound, from which a slight oozing of blood charging a thin purulent fluid. There is shortening of the existed. Pulse 84. To have nothing but a little thin gruel limb of about an inch, and by laying hold of the lower part of and cold water. Eleven P .III.: He has been dozing a good deal the femur, and rotating it, the head of the bone can be dis- since the operation; feels pretty comfortable; oozing from the tinctly felt on the dorsum ilii, and it is evident that no anky- wound has stopped; pulse 104. June 15th.-I was delighted, when I entered his room, to losis or attempt at such has taken place. By introducing a probe through the above-mentioned opening, it can be carried see this patient doing so well. There has been no shock at in various directions, but particularly over the head of the bone; all; he has passed a comfortable night; febrile action modeby the most strict examination, however, no bare bone can be rate ; tongue slightly furred; pulse 120, very feeble; comdiscovered. He complains of great pain when the limb is plains of thirst; wound looking healthy; takes nothing but moved, and when pressure is made over the head of the femur. gruel and barley-water. I dressed the wound with warm There is no fulness in the iliac region, no tenderness there, water. and nothing amiss in the lumbar spine. The man, who has 16th.-Has passed a good night; complains of very little been a fine, tall fellow, is much wasted, has become very pain in the wound,which is now beginning to discharge matter of a healthy character; no immoderate swelling about the weak, perspires at night, and has a rapid and feeble pulse. After carefully looking at this case, I expressed my opinion wound; pulse 110, and somewhat fuller; has taken a little to Dr. Milroy, that it was one of those in which the surgeon mutton broth to-day, which he relished. 18th.-Yesterday there was a little tenseness about the might take into consideration the propriety of some operative proceeding,-of an exploratory character, at least,-and then wound, but to-day this has disappeared, and he is doing adact according to circumstances. It appeared to me, that the mirably ; sleeps well; eats an egg night and morning; granuhead of the bone was the part principally affected; and that, lations of a healthy character are appearing in the wound; dislying as it did in its abnormal situation, it was acting as the charge from it moderate, and of a bland appearance; pulse 98. source of irritation, and was gradually destroying the patient. 20th.-Still rapidly improving: his bowels (which had been It was evident that there was no disease of a very serious well cleared of their contents previously to the operation, in nature in the pelvis. Taking this into consideration, and to order that he should not be necessitated to change his position. what an extremity the patient was reduced, I did not hesitate while the wound was in a fresh state) have not been moved to regard this case as one for which the operation of excision since; and he is to take a table-spoonful of castor-oil. Granuof the head of the femur was adapted. It was determined, lation of the wound going on rapidly. To have half-a-pint of however, that we should be in no hurry about the operation, ’ beer daily. 21st.-In consequence of the rather severe operation of the but would watch the patient and examine him carefully from time to time. physic, he has not been so well. Pulse 84: more feeble. HeI Subsequently to this, my friend Mr. Walton, and Messrs. complains of pain below the wound, and on looking there, Arnott and Shaw, severally saw the case, and agreed with me find a slight blush, and swelling of the part-but the wound in the opinion I expressed of the nature of the disease, and in itself is looking remarkably healthy. I ordered the uneasy the propriety of making some exploration of the parts with part to be well fomented, and the patient to take a small porthe knife. Before resorting to any measure, I determined to tion of solid meat. have the benefit of Mr. Fergusson’s experience. That gentle23rd.-Doing well; he complains no longer of the pain man kindly visited the patient with me, and after a careful below the wound, and the inflammatory blush has subsided; examination, expressed his conviction that it was one of those his appetite is good; tongue clean; discharge of a very healthy cases in which the surgeon ought to interfere, as the disease character, and moderate in quantity. 27th.-Since last report, this patient has been progressing appeared to be limited chiefly to the head of the femur, and the patient had no chance of recovery from any natural or most favourably; he is beginning to feel stronger; appetite remedial measures. good; pulse under 100, and fuller; the wound has healed up As the patient was living in a small, confined room, with to a great extent; the discharge is still abundant, but partiseveral children about him, I had him removed to the neigh- cularly healthy. He still perspires at night; he takes meat bouring house of one of his relatives, where he could get and beer daily. I ordered the following-Sulphate of quinine better air and more attention, and it was determined that the one grain; diluted sulphuric acid, twenty minims; water, an operation should be performed after he had remained quiet ounce. Mix for a draught, three times a day. for a few days in his new lodging. In the meantime, Dr. Mil29th.-The wound has now so nearly healed up, that I thisroy carefully examined the condition of his health, and the day placed the limb (which since the operation has been state of the patient’s lungs, and found nothing in those respects lying somewhat in the same situation as it was before the, to contra-indicate an operation. Accordingly, on the 14th of operation, with a much contracted knee) upon a Liston splint; June, I excised the head of the femur, in the presence of Pro- and got it into a much better position, intending daily to exfessors Fergusson and Partridge, Messrs. Arnott, Walton, tend it. This operation gave the patient considerable pain, and caused the wound to bleed somewhat. Bowman, Ure, Shute, Nunn, Bishop, &c. July 8th.-Since the last report he has not been doing soOperation.-The patient having been placed under the influence of chloroform by Dr. Snow, and laid on a table on his well ; he complained much of the operation of placing the right side, I commenced an incision over the head of the bone, limb on the splint; and lie has been suffering as much constiand carried it to the extent of about seven inches in the direc- tutional disturbance as he did after the original operation. tion of the shaft of the femur. By this the head of the femur There has evidently been caused a fresh attack of inflammawas exposed, and it was discovered lying in the midst of an tion in the part, as indicated by profuse suppuration, and a abscess, and in a carious condition. The tissues were then partial re-opening of the wound, and tenseness and swelling cleared away from the neck and trochanter, and in order to about the hip. The tongue had been furred, pulse quickened.
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making any way. Now, however, yet very incomplete; nor do they frequently take much pains this disturbance has ceased; tongue is clean; appetite good; afterwards to improve it. Their advancement has not been the wound looks very healthy, and the discharge is moderate, sufficient to induce them to pursue such studies as a source of and of a good character. He still perspires at night. The mental enjoyment; and their time is frequently occupied in a limb has been daily extended, and it is now much straighter. manner notvery favourable to a literary taste. The conTo have two glasses of wine daily. sequence is, that the scanty knowledge with which they left 14th.-Progressing favourably. The wound has contracted, school becomes daily diminished in degree, until at the end of and healed much, and the discharge comes only from one or their apprenticeship it has dwindled into utter insignificance. In this place it is impossible to avoid adverting to the pretwo small places. The limb is now very nearly straight. valent system of apprenticeship as required by the Society All the functions of the body are well performed. 22nd.-He has, during the last few days, had an attack of of Apothecaries. We scarcely know in what sufficiently diarrhoea, attended with griping, which has pulled him down strong terms to express our sense of the impolicy and pernicious tendency of these apprenticeships, as an integral part a bit; but this was checked by regulating his diet, and the The limb has become so straight, of professional education. We do not mean to deny that use of aromatic confection. and the wound so far healed, that I have taken the splint off, some useful knowledge is obtained in the course of their and laid the leg on a pillow. There is still a considerable duration; but, generally speaking, it might be gained on much amount of discharge, of a healthy character, however. He easier terms by a different arrangement, while much that is has for the last few days complained of pain on the outside pernicious in habits of idleness, and too frequently of moral of the thigh, a few inches below the wound, where there is a depravity, might in a great degree be avoided. In almost blush of inflammation, and a feeling as though matter were every instance, we believe, the five years of apprenticeship, taken from that period of life when the mind is most capable forming. I ordered it to be well fomented. August 2nd.-Nearly all swelling has gone down. There has of useful training and of profitable application to study, might been a free and healthy suppuration, which now, however, is be disposed of in a manner incalculably more beneficial-in but slight. The wound is looking in a most healthy condition,the acquisition of the classical and mathematical knowledge to the length of an inch and a half. The already referred to as so indispensable, and of various other and has patient is ableto move the thigh somewhat, and is gradually branches of general acquirement calculated to develop the regaining his strength. He eats and sleeps well, and com- mental powers, and prepare them for the subsequent duties plains of no pain. He has been taking, for the last few days,, of life, social and moral, as well as professional. a mixture of iron and quinine. But it may be asked, Ought not the student in medicine to 28th.-Since the last report the patient has been gradually have a knowledge of pharmaceutical preparations !-Ought he progressing, and he is altogether in as favourable a condition not to be familiarized with the various substances employed in the relief of disease-with their appearances, their mechaas could be expected. The wound has nearly healed up. A considerable discharge has been kept up from the various nical, chemical, and remedial qualities-their doses, modes of sinuses which existed prior to the removal of the head of the preparation, and of exhibition or application ? Without bone, and which necessarily take a long time in closing. doubt, all this ought to be the case; but much of it cannot There were some indications of matter down the thigh some be learned at all, or at least but very imperfectly, during an few days ago, consequently I made a deep counter-opening a apprenticeship, and the rest might be as conveniently acfew inches below the wound, but without evacuating any pus. quired without it. But besides all this, many prejudices and The movement of the limb is much more free; and I have false notions are frequently imbibed in relation to the nature every reason to suppose that a new joint has already partially and objects of the profession, which are with difficulty, if at formed. The general health is satisfactory; the appetite all, subsequently laid aside, and give an unfavourable colourgood. The night-sweats have left him. The pulse has become ing to the future progress of education. These facts connected with medical apprenticeships are full, and moderate in frequency, and the man is slowly revery generally acknowledged; but still it is thought that they gaining flesh. cannot be dispensed with, as a necessary means of enabling Caroline-street, Bedford-square, November, 1848. the practitioner to conduct his business, particularly the (To be continued.) pharmaceutical part of it. This places the subject in a totally different point of view. Let it once be admitted that apprenticeships are intended, not for the instruction of the pupil9 AN ESSAY ON MEDICAL REFORM; but for the cmavenience of the practitioner, and we may feel. WITH SUGGESTIONS FOR THE RE-ORGANIZATION OF THE MEDICAL assured that the system is tottering to its fall. It is simply PROFESSION. one of pecuniary profit; and surely this ought not to be placed BY THOS. MICHAEL GREENHOW, ESQ., F.R.C.S., &c., in competition with the intellectual and moral welfare of the Newcastle-on-Tyne, student, and his future proficiency in professional knowledge. SURGEON TO THE NEWCASTLE INFIRMARY AND EYE INFIRMARY. It is doubtless convenient for the practitioner to procure persons to prepare his prescriptions without pecuniary charge, "Sed longe alia est ars medica, et longe aliis difficultatibus implicita." but nevertheless he might obtain more competent assistants for this purpose, were he denied the opportunity of taking (Concluded from p. 402.) apprentices. [WANT of space precludes our publishing the whole of Mr. It is clearly required of the enlightened physician, to know Greenhow’s observations, but in the following abstract we all that can be known by the most skilful surgeon; nor is it present our readers with the main points which he desires to less essential to the latter, to possess all the knowledge of the most accomplished physician. What then follows ?1 If all urge on the attention of the profession.]-ED. L. the members of the profession are thus required to pursue After having given a brief history of the medical corpora- a definite and comprehensive course of study, and to give tions, the author proceeds thus :public proofs of equal proficiency, they are surely entitled to We shall not enter into any detail of the curriculum of receive equal honours, and one general designation. As professional study which every student should be required to regards titles, privileges, and qualifications, all distinctions, pass through; it ought to include every branch of natural therefore, ought to be abolished. This may be called a science that can in any degree bear upon an enlightened com- levelling plan, a term which is not generally received with prehension of the nature, causes, and cure of disease, and it much favour, but if it be a levelling plan, it is one of an ought to be ample as to time. It is of little consequence that unobjectionable character; its purpose is not to bring down a highly-gifted mind here and there may be enabled to acquire the hills to the same plane with the valleys, but to raise the a full share of knowledge in a shorter space of time, and withlatter to the altitude of the former, that all may begin their out pursuing that systematic course of study which is abso- career in life, so far as legislative arrangements are concerned, lutely necessary for the complete instruction of ordinary minds. with the same opportunities of gaining professional knowLegislation must have reference to the many, and not to the few; ledge, and the same, or at least a high degree of actual attainand the regulations which it lays down must be of a general, ment. But here the equality ceases; a thousand circumnot of a partial character. It will, we think, scarcely be denied stances, personal and adventitious, will soon establish distincby any one acquainted with the ordinary attainments of youths tions, not in legal privileges, but in public estimation, in who enter themselves as medical students, that their pre- professional reputation, and, by consequence, in pecuniary paratory education has, in a large majority of cases, been emolument. But if equal qualifications are to be required from all the very imperfect. They are generally bound apprentices between their fifteenth and sixteenth years, when their know- candidates for professional honours, and all are to be designated ledge of classical literature and of mathematical science isi by one common title, it is evident that all must have their
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