cupying one side of the abdomen, extending from the right iliac region beyond the median line towards the left, and above the umbilicus. Tumor apparently solid. I say apparently, for it is not easy to diagnose the liquid contents of such tumors, if liquids be in them, especially if the walls be thick, and the cavity within be formed of two or more noncommunicating sacs. Examination per vaginam discovered a solid tumor filling most of the pelvis, and which seemed to be a part of the general mass above described. This patient suffers much from her disease. At times the bladder and urethra are so compressed that urine cannot pass. At times the rectum is obstructed. The result is most severe pain and distress throughout the abdomen. The trouble here is spasmodic, and at times exactly resembles violent colic. In the intervals of these attacks she was able to do some work in a family, to walk the streets, &c. She had for some time been engaged to be married. A desire had been manifested to have the engagement broken off. I was consulted. I gave an opinion decidedly in favor of the measure; and had there been a legal question raised, I should have felt it my duty to state that such an "impediment" (I use the word in its ritual technicality) existed as made the state of marriage improper. I remembered well a case of recent marriage, in which the husband desired my advice on account of important disease, not known to exist before marriage. I discovered that a tumor absolutely filled the whole cavity of the pelvis, and which, if it continued to grow, would in no long time be seen externally.

I began an active course of treatment very soon after I saw this case of E. L. The diet was regulated, so was exercise and rest. lodine ointment was constantly applied over the whole extent of tumor; and sol. mur. lime was steadily given. She took of this larger doses than has any other patient to whom I have prescribed it. The dose amounted at last to about three hundred drops, three times a-day. Leeches were used whenever pain existed in the tumor, and occasionally counter-irritation was employed. This course was persisted in for a long time. The tumor gradually diminished. This was ascertained by careful admeasurement. The strength returned. She gained flesh. She has for a long time passed from my professional care, but I occasionally see her, and always learn that she has no complaint. I have made no examination for a long time; but I feel sure that if the disease had become active again, I should have

known it.

Remarks.-Mrs. K.'s case, No. IV., occupies a large space in this record. It was a case of much interest. It involved some important principles. Are we authorized to operate in such cases? How far are we to be influenced by our patient in deciding such a question? Here was entire faith in what was to be done. It was faith in it as the only means of life-offering the only chance, however faint, that was of good. It was associated with an intense desire to live. The disease, called by C. M. Clarke and others malignant, has within a few years been successfully treated by ligature. The immediate effect of ligature in this case was good. It lengthened life, and made

life comfortable. I do not recollect a circumstance in this case which brings with it any regret that the operation was done. A question has been asked above, how far shall the physician be influenced in his judgment in treating disease by the demands, or wishes of his patient? As a rule, and the demand existing by itself, there being nothing in the case which promises good from any known agencies, he is not to be influenced at all by the wishes of his patient. But cases do occur which form, or are regarded as exceptions to the rule, and the physician is, and will be, governed by them. I remember, when a hospital pupil, a sailor entering the hospital for an affection of the heel which renderd him perfectly useless, and for years, under all sorts of treatment, had made him a great sufferer. He came to have his leg cut off. He had hobbled over the country, and applied for the radical treatment in vain. His leg, heel, foot, all, had not the slightest appearance of disease about them. His demand was heeded, his request granted, and he had the operation done with apparently as little suffering, certainly with as little complaint, as if he had been under the fullest power of ether.

I remember another case. It occurred in Scotland. An unmarried woman had a swelling of the abdomen of great size. It troubled her extremely. It did so principally in preventing her getting employ. ment, she being supposed pregnant. This was a sore charge, and most grevious in its consequences, for she depended on work for her living. She roamed about to have an operation done on the abdomen, by means of which a large tumor, which surgeons regarded her trouble to be, might be removed. She applied in vain, till at length Mr. Lizars, then of Edinburgh, consented to do the operation. An incision was made of great extent, into the peritoneal cavity. But no tumor was found. The abdominal intumescence was owing entirely to a very large deposit of fat in the walls of the abdomen, and a very fat omentum.

In deciding the question of an operation in the cases referred to, the surgeon acts upon his own responsibleness, and his sense of this must determine for him what the practice must be.

A word more. In cases V. and VI., of polypi of the womb, it is said that pain was complained of when the ligature was tightened, and that soreness of the abdomen followed. The same was said of

tightening the ligature in Mrs. K's. case. Now these three tumors are insensible, wholly so, certainly were they in the cases referred to. Whence, then, the pain? I have already answered this question, by supposing that it happened from the nearness of the ligature to the proper substance of the womb itself. The tumors had no pedicles. They sprung from broad bases, and the ligature was applied very near to the base. The womb, though no portion of it was included in the ligature, did receive pressure from the ligature applied so near to it. Now it is not important that the ligature should embrace polypi round the pedicle, or very near the base, especially in cylindrical or globular polypi which have no pedicle. If the ligature be applied at such a distance as not at all to affect the womb, the whole of the

tumor will drop off, just as does the whole of the umbilical cord, let us leave what amount we may adherent to the abdomen.

But if the pain on tightening the ligature be such as to attract regard-if it be accompanied by the constitutional or local symptoms of uterine or peritoneal inflammation, slacken or remove it at once, and treat the disease it has produced at once with appropriate remedies. When applied again, select a spot more distant from the womb. Make the pressure less severe if pain again accompany it. If there be no pain, make it firm enough to strangulate the tumor at once, or as far as may be, as less constitutional trouble is apt to arise from such an operation, than from a less perfect and positive one.—Boston Med. and Surg. Journ.

Prosecutions for Mal-Practice in the State of New York.

To the Editor of the Boston Medical and Surgical Journal.

SIR, I saw, by a notice in a late No. of your Journal, that a physician in Delaware County, of this State, had been prosecuted for mal-practice in the treatment of a surgical case. Perhaps a brief history of the case, treatment and result, in connection with another of alleged mal-practice in surgery, disposed of last week, in the Washington County Circuit Court, may not be uninteresting, if not instructive to the medical profession.

In giving the report of these cases publicity in a widely-circulated medical journal, I trust the public interest may be subserved, and the junior members of the profession benefited. I desire not to wound the feelings of any professional man; and shall, therefore, avoid giving the names of the physicians charged with the mal-treatment of the following surgical cases.

Some time about the 11th of September, 1845, two young men, both "posse men," or in the employ of the State, during the late antirent difficulties, were wrestling; one of whom was about to be thrown upon the ground, and in the act of falling, thrust out his left hand, which met the ground rather outwards and backwards from his body, receiving not only the weight of his own body, but in all probability that of his antagonist; which resulted in a fracture of the external condyle of the humerus, and a backward dislocation of the ulna. In fifteen or twenty minutes after the receipt of the injury, the patient was placed in the hands of a young physician, who, I believe, regarded the accident a backward dislocation of the elbow.

By the testimony it appeared that he attempted to reduce it, by directing one person to make use of counter-extension from the humerus, midway between the shoulder and elbow, and another individual was directed to extend upon the fore-arm, by grasping the limb at the wrist; while the physician, by the aid of his own hands, endeavoured to crowd the articulating extremity of the humerus, situated in what should be the hollow of the arm, backwards. The extension and counter-extension was applied while the limb was in the extended or straight position; and after the application of considerable force, for some little time, there was an apparent yielding, when the physi

cian would direct the limb to be slightly flexed, which twice resulted in something like a "chuck backwards." At last, on a third trial, extension and counter-extension was applied as in the other two instances, and the limb left nearly in the straight position, with little or no effort made to flex it. It was pronounced reduced; and the patient thought" it felt more like an arm." The degree of flexion can be pretty accurately estimated, when it is stated, that in order to make a sling sufficiently long to suspend the limb over the opposite shoulder, it required, or, at least, two handkerchiefs were tied together, and used in the ordinary way.

The physician saw the patient from time to time, for about thirty days; and up to near this period, said that "it was all right, or as near as it could be, except a little point of bone or process, which would come right by using the limb."

At the end of seven or eight weeks, the patient called on me at one of our Saturday cliniques at the Albany Medical College, with his elbow swollen, stiff, and in nearly the straight position. The lower end of the humerus could be felt quite distinctly at the fore part of the joint, and the olecranon projected unnaturally behind; in short, the ulna was, at that time, dislocated backwards. I made a vigorous, though unsuccessful, attempt to reduce it. In the great exertion employed to flex the limb, and the effort to dislodge the coronoid process from the olecranon fossa, the extreme point of the olecranon process gave way. The fore-arm, however, was brought to something more than a right angle with the arm, which would have been in a much more useful position, if, as we anticipated, a joint but little better than anchylosed, should be the result. By neglect on the part of the patient, and by the weight of the fore-arm, the limb at length returned to a state but little more flexed than at the time when I first saw it, and thus remained stiff and inflexible.

In something less than a year after the accident, the young man, by the advice of his friends (not medical,) commenced a suit for damages; charging, in his declaration, that the joint was then dislocated; that it had never been reduced, and consequently that he had, in a great degree, lost the use of his limb. That a backward dislocation of the ulna existed at the time of the trial, neither the defendant nor witnesses pretended to deny, and that a great share of the difficulty and loss of the use of the limb was to be attributed to the dislocation.

The counsellor for the plaintiff endeavoured to show, that the malpractice consisted in the fact, that the defendant did not make use of the most common and best means to reduce the dislocation; and that no evidence, at the time of the attempted reduction, was had, to show that the dislocated bone had been replaced.

One of the first questions put, on the part of the prosecution, was, "What is the present condition of the elbow-joint of the plaintiff; and what was the original nature of the injury?" All agreed, that there was a fracture of the external condyle, which presented its proper relation to the head of the radius, and that there was a dislocation of the ulna backwards. Some of the witnesses thought that the

coronoid process of the ulna was broken off; and others, that the fracture, which carried away the external condyle, extended through the trochleal articulating surface of the humerus, so that by the action of the muscles, the coronoid process (provided that it was not broken off) was drawn, as it were, between the fragment and the continued shaft; or, in other words, that the articulating surface of the humerus was not sufficiently broad to sustain the ulna, after having been brought into its proper place. These two points, together with a feeble attempt to show that the patient had been imprudent in walking about too soon; in permitting a friend or nurse to dress it; and in riding on horseback, constituted the chief grounds of the defence.

On the part of the prosecution, after inquiring into the condition of the limb, nature of the accident, &c., the question was asked, "What is the evidence of reduction of a dislocated limb or joint?" All the witnesses, both for prosecution and defence, replied, “restoration of the form and shape of the joint, and freedom of motion.

The next question asked, was concerning the proper mode and means to be employed in reducing a backward dislocation of the ulna: and without a single exception, all replied, that it would be proper to apply extension and counter-extension while the elbow was in a flexed position. This principle was too obvious to be denied, or controverted, from the clear and conclusive demonstration made by the aid of the os humeri and ulna. By flexing the joint, the coronoid process was brought out, and forward from the deep olecranon fossa; and by extending it, it was made to lock into the deep olecranon fossa, and there retain its hold with great firmness.

The book authorities, with the exception of a single case given by Sir. A. Cooper, in his work on Dislocations, direct that the limb should be flexed, as by bending the joint around the knee, or around a bed post. It was agreed by all the medical witnesses, that if the limb was flexed, and, at the same time, if a separating force were applied to the extremities of the two bones involved in the dislocation, whether by the hands, or in any other way, such a dislocation as that under consideration might be reduced.

Another question asked the medical witnesses, was this: "If the coronoid process be broken off, would it not be proper, and the authorized practice, to place the limb in the extended position; or would it be correct practice for the treatment of the fracture, espe cially if there had been a backward dislocation of the ulna?" The question was also asked, "Should the limb be placed in the semiflexed or flexed position?" To the former question all answered in the negative; and to the latter, the same reply was made by all the physicians, with the single exception of a young man who was then practising dentistry, and who testified that he was a graduate in medicine; had attended lectures in New York; and had there received instruction in the lectures of the Professor of Surgery to treat fracture of the coronoid process of the ulna, by placing the elbow-joint in the semi-flexed position." I find no authority for this practice in any surgical work with which I am acquainted; nor have I learned that