18th.-Had some nausea yesterday afternoon, which soon went off. He continues well. Four evacuations since yesterday evening. Pulse 106. 19th.-Continues well; a great part of the wound is healed; discharge less; pulse 103; one evacuation from the bowels. The wound to be dressed with a lotion of the sulphate of zinc. 26th. Since last report the patient has been daily improving. The stump is almost healed, and his health is quite good. The distinction between Necrosis or death of bone, and Caries, or incurable ulccration of it, is now fully understood and discriminated in practice, but the combination of these morbid states has not been so much attended to as it deserves. In the lower end of the thigh bone it is far from unfrequent. The causes are usually blows, strains, or the indirect irritation of exposure to cold. The symptoms are enlargement of the bone, from the condyles to more or less extent upwards, followed by suppuration, and in general the discharge of exfoliations. The distinctive character between this affection and simple necrosis is the participation of the condyles in the swelling. And the distinction should be carefully made; since, while simple necrosis is a disease that tends to its own cure, and seldom requires much interference, the caries that complicates the case, exhibits its peculiar obstinacy, and renders recovery quite hopeless. The predominant features of the discase being those of necrosis, are apt to lead away from the suspicion of caries, and induce the attendant to abstain from performing amputation in the vain expectation of a natural cure. I have met with many cases of this kind, some of which have been related in the former Reports; and lately amputated a thigh which had been thus affected during the long period of thirty-nine years, having first suffered when the patient was eleven years of age. When the true nature of this mixed disease has been recognized, no doubt can remain as to the propriety of recommending amputation; and if the operation is performed in youth, while the system has more power of accommodation to circumstances, and has not become habituated to the disease by long endurance of it, the patient will not only be saved a length of protracted misery, which must embitter his comfort and impede his usefulness, but also be saved the danger, or rather certainty, of a fatal issue, which must attend the removal of the limb at a more advanced period of life. Excision of the Elbow Joint.-George Muir, aged 10, from Selkirk, was admitted on the 9th of March, on account of a diseased elbow-joint. There was a large ulcer, nearly two inches in length, over each of the condyles of the humerus, through both of which a probe could be readily passed to the bone. The boy looked rather pale and sickly. It was stated, that the disease had commenced spontaneously about three months before. The operation was performed on the 12th. It then appeared, that the humerus was chiefly affected, and a portion of it, not less than an inch and a-half in length, required to be removed. The other articulating surfaces were detached, and the after-treatment conducted as usual. He was not confined to bed after the third day, and in a fortnight began to use the arm. He was dismissed on the 9th of April. Excision of the Elbow-joint.-Boaz Simpson, aged 13, was admitted on the 29th of May, on account of a diseased elbowjoint. It was very much enlarged, stiff, and discoloured. Various sinuses, opening at different parts on all sides of the limb, led down to the bones. The arm both above and below the elbow was extremely emaciated. The patient was of very small growth, and had a short dry cough; but took his food well, and was in other respects healthy. It was stated, that the disease had commenced between three and four years ago, with the formation of an abscess, independently, so far as could be learned, of any external violence, and had since advanced progressively notwithstanding every attention. It was evident that recourse must be had either to excision or amputation, and though the patient certainly did not seem a favourable subject for either, or indeed for any operation, the former did not appear to be attended with more danger than the latter, while the preservation of the limb was evidently a most important object. The operation was performed on the 7th of June in the usual way. The whole of the articulating surfaces were removed. The patient suffered hardly any constitutional disturbance, and on the third day was allowed to sit up. The discharge in a few days almost ceased; and in the course of a fortnight he could use the arm a little. He was detained in the Hospital until the 5th of August, in order that his progress to complete recovery might be observed, but might have been dismissed much sooner, as for several weeks there had been merely a few drops of serous discharge daily. James Topings, who was operated upon last October, and whose case is related in the preceding report, was in town a few days ago, and afforded us an opportunity of seeing that the limb was perfectly sound, without swelling or deformity, and capable of performing its usual motions of flexion, extension, pronation, and supination. The following letter, which was lately received from another patient, whose case has been related in a former report, may perhaps tend to confirm the opinion of those who think well of this operation. WORTHY SIR, Cupar-Fife, 5th August 1833. I take this opportunity of again expressing my gratitude towards you, and to let you know to what perfection my arm has arrived at since you operated upon it in 1830, July 15th. I wrote to you as I promised as soon as I could hold the pen, as you know it is my right arm, and with it the office of writing is performed. I think it was about the 5th December 1830, when I wrote you that it was almost whole, but very weak. I have now to state to you what I have been employed at for nearly this two years, and how my arm performs its duties. I commenced grocer and spirit-dealer in this burgh about two years ago, and I find my arm quite sufficient for this business. I can carry eighteen or twenty pounds with ease, put six or eight pounds up to my head with it, make out accounts, &c. so that no person would know whether I had my elbow-joint or wanted it. I have even asked some people if they thought there was any thing the matter with my right arm, which they answered they could discover nothing. I most certainly think the case of my arm a very wonderful one, on account of the great strength and flexibility it has gained. I must attribute this to your admirable operation. If you had not operated upon it I could not have expected to live long, as my health was very much impaired before I applied to you. But Divine Providence has ordered it otherwise. I am now enjoying as good a state of health as ever I did. Accept of my most grateful thanks; and may Heaven bless you for all your kindness and humanity towards me.-I am, Worthy Sir, your obliged and humble serDAVID FORREST. vant, It does not seem necessary to notice particularly the other operations that have been performed, viz. Two amputations of the leg,-several excisions of the mainma,-amputations of fingers and toes, with and without metacarpal and metatarsal bones,-fistula in ano,-hydrocele,—polypus,-enlarged tonsil, and other small operations. ART. VIII.-Description of the Midwifery Instruments of UPON a former occasion, I endeavoured to give a histori cal analysis of the English midwifery forceps, and to point out the various improvements and changes which they had undergone, from the extractor, as used by Giffard in 1726, to the more per fect instrument, as left us by Dr Smellie. I now take the liberty of calling the attention of the Society to an earlier, and perhaps even more interesting, period of their history. Having received permission of the president of the MedicoChirurgical Society to inspect the instruments which were found in 1818 at Woodham in Essex, and which, there can be no doubt, belonged to the celebrated Dr Chamberlen, a number of interesting facts presented themselves to my notice; and as no description of them has hitherto been published, an account of these instruments, and the chief points of resemblance between them and the various extractors, levers, &c. of the above-mentioned period, will form the object of the present inquiry. It is well known with what a degree of mystery the Chamberlens had enveloped their secret, and what pains they had taken to keep the world in perfect ignorance as to the nature of it, not only during their own lifetime, but also for succeeding generations. Still, however, the forceps appear to have been known among a few practitioners in England at a very early period; because those which belonged to Mr Drinkwater, "who began practice in 1668, and died in 1728," as far as can be ascertained from Dr Johnson's description,* very much resembled the more finished specimens among the instruments under present consideration; and it is much to be regretted that neither Giffard or Chapman have given us any information as to whence they had obtained their instruments. Chapman, who, as far as I can judge, used the forceps as early as Giffard did, does not appear to have received them directly from the Chamberlens, as he evidently expresses himself uncertain as to the nature of their secret, although there was every reason to presume that it really was the forceps. + Chapman was the first in England who published a description of these instruments; and for some time afterwards, both in this country as well as in France, they were known as Chapman's forceps; and, with the exception of some trifling changes, continued to be the French forceps, in the hands of Gregoire and Levret, until 1751. Although these instruments were considered to have been originally the Chamberlen secret, still so completely had the nature of it been concealed by its inventor, that even in 1751 Exton & doubted whether any instrument had been used at all, supposing that the Chamberlen secret was merely an easy method New System of Midwifery, by R. W. Johnson, M. D. p. 170. + Chapman's Midwifery, p. 5, 2d Edition. Smellie, Vol. 1. Book 3, Chap. 3, Sect. 2. § Exton's Midwifery, p. 5, Introduction. of turning. There were, however, no grounds for this supposition, because Chamberlen himself, in a note to his translation of Mauriceau, says, "this chapter might be very well spared, if every practitioner had the art the translator professeth in his epistle, of fetching a child, when it comes right, without hooks or turning it." * The chapter alluded to is entitled, “How to fetch a child, when coming right, it cannot pass, either because it is too big, or the passage cannot be sufficiently dilated." And even if Chamberlen had not made this observation, the morbid dissection of the poor woman in 1670, who, Mauriceau had declared, could not be delivered except by the Cæsarean operation, and whom Chamberlen had in vain attempted to deliver, gave but too evident proofs that an instrument had been employed upon the occasion. This poor woman, (says Mauriceau) with her infant in utero, died in twenty-four hours after the extreme violence which he (Chamberlen) had used towards her; and on opening her body after death, and making the Cæsarean section, which, as I have already stated, I was unwilling to do during her life, I found the infant and every thing else situated exactly as I had previously described, and the uterus entirely lacerated and pierced through in many places by the instruments which this physician had blindly used without introduciug his hand." It is singular, that in the only country where Chamberlen first disclosed his secret, viz. Holland, and where he made it known to Roonhuysen as early as 1693, the nature of it was not generally known until De Visscher and Van de Poll published a description of it in 1753, exactly sixty years afterwards; and even then the lever, as used by Roonhuysen, seems to have been a most imperfect instrument; and I am much inclined to doubt if this was the instrument which Chamberlen generally practised with. I am led to this supposition, from the fact that Palfyn of Ghent, after having made several journeys to London and Amsterdam, for the purpose of ascertaining, if possible, what was this celebrated secret, at last succeeded in obtaining so much information about it, that he was enabled to form the tire tête, which he presented to the Academy of Sciences at Paris, and which afterwards, with some modifications, became the forceps of Dusée and Butter. This instrument consists of two blades, without fenestræ, which were introduced on each side of the child's head, and tied together at the handles without crossing; nor can I conceive that the result of Palfyn's inquiries (which could only have been made among those women who had been attended by • Chamberlen's Translation of Mauriceau, Chap. 17. |