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Association Medical JournalSource: Association Medical Journal, Vol. 4, No. 164 (Feb. 23, 1856), pp. 148-150Published by: BMJStable URL: http://www.jstor.org/stable/25497042 .

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148 ASSOCITION MICAL JOURNAL [FZB. 28, 186

ved in to heel Asp, and cutting it as low as poable, somtimes even below its division into the t inaplantr branches, in order to secure an adequate cula supply to the tisues which compose the fap, has been so fuly in isd upon by all practical surgeons, and especiall by the

author of this operation, Mr. Syme, that it will be unneces sy to do more than allude to it here. The object can

olay be attained by keeping the point of the knife close to the bone in the dissection, and carefully defining its con tour throughout.

The principle of not injuring the flap is equally impor tant, and is to be secured by the same method of manipu lation. Moreover, no violence should be used in endea vouring to turn or push the flap backwards over the posterior extremity of the os calcis, in order to facilitate the dissection: the part does not possess a very high degree of vitality, being composed largely of cellular and adipose tissues. These structures, with their capillary circulating apparatus, may very easily be crushed by undue handling. This is a point which Mr. Syme conceives to be one of no slight importance. For the same reason, it is highly essen tial that the dressings should be simple, and lightly applied.

Nothing should be permitted to interfere with the circula tion. There is no more important part of the operation than this, if it may be so called, as I believe it ought. In none is it more necessary for the surgeon to act with care and delicacy. The indication consists in approximating and supporting the flaps, in making none but gentle pressure, and in using no force or constriction.

The third point is that to which I venture to request particular attention.

It has always appeared to me that the thick and hollow flap which it has been customaty here to make from the heel in this operation, bas opposed considerable obstacles to the subsequent well- doing of the case. In the first place, it is physically impossible that such a flap can be brought into apposition with the surface with which it is neverthe less intended to unite. Secondly, it becomes a receptacle for the blood which must, more or less, be effused after the operation when no support exists upon the parts to prevent it; and afterwards it retains by its form the suppurative discharge which is often present in considerable quantity.

With these obstacles, the granulating process is often greatly delayed, and the wound is very slow to heal. Lastly, the distal portion of the flap not unfrequently sloughs, the result of which is an improvement in its form, and at the same time an indication by nature, as it would appear, of that which should have been assigned to it at the outset by the surgeon.

These sources of delay, depending as they do upon the form of the flap, might, I think, be very advantageously removed by carrying the lower incision further back than it is generally the custom to make it here. Not only does the case do better, which is the primary consideration, but the dissection of the heel flap becomes infinitely easier of performance-a matter which it would be affectation to overlook or regard as unimportant.

In a clinical lecture published in the Lacet of March 25th last, Mr. Syme points out the inconveniences which may arise from the too great length of the heel flap; and I think he seems to recognise them more fully there than in any other description of his operation which he has previ ously given to the profession.

The accompanying diagram illustrates my meaning. The figure shows the inner aspect of the skeleton of the foot

and lower third of the leg, with an outline representing the relation of the overlying soft parts. The dotted lines, ab, ac, represent the upper and lower lines of incision described: a also points out the inner malleolus. The prominence on the under surface of the os calcis is seen just above c, with the hollow immediately in front of it. It will be sufficiently obvious that, if we draw a line of incision from a, in a nearly vertical direction downwards to d, the knife will enter the hollow, and, in the subsequent dissection of the flap, encounter that prominence, which the operator will probably have some difficulty in clearing successfully, be

sides having large hollow flap to deal with, the disdn.. tages of which hare been already pointed out.

In fact, all that is wanted is a flap, taken in part from the thick cushion which forms the posterior part of the heel, sufficiently large to amplv cover the cut surfaces above the ankle-joint-a flap in which some, if not a consi derable portion, of union by first intention may be reason ably anticipated. It is no small objection, I conceive, to that modification of this operation by Professor Pirogoff in which he retains the posterior half of the os calcis, and thus gets rid of the dissection of the heel flap, that the union of the two bony surfaces thus involved must be tedious, on account of the suppuration, granulation, and secondary adhesion by which the cicatrisation of the wound

must necessarily be preceded. I have reason to know that it is so in practice, and do not make that statement on a

przori grounds alone. What advantage it offers in com pensation fer this somewhat serious result, I am at a loss to uniderstand.

SATURDAY, FEBRUARY 23RD, 1856.

THE MEDICAL REFORM BILL.

Ma. HEADLAM'S Medical Reform Bill was read a second

time on Wednesday last, without a division; and stands

for committal on the first Wednesday after Easter. In

the interval which will elapse before that day, it behoves

every member of the profession who values the position of

his own body, and the interests of medical science, to bestir

himself in favour of this excellent measure. There is not

a town in the kingdom which has not at least several me

dical men among its inhabitants; and there is not a town,

consequently, which ought not to send up a petition to Par

liament in support of Mr. HIeadlam. We earnestly impress

on every member of the Association the duty of thus ex

erting himself: on the energy displayed in petitioning wiU

depend in a great measure the success of this best attempt

to settle finally the question of medical reform.

Many medical men, we are aware, are hanging back at

this juncture, under the impression that any exertion they

may make will be throw away, as similar efforts have

often been before. But let them at once undeceive them

selves in this respect. This Bill is no flash in the pan: it

has been brought in by an earnest and able man, who un

derstands the work of legislating, and has succeeded pre

viously in passing more than one contested measure; it

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73. 2, 186.) AI ON MICAL JOARNA 149

bas the support, to a great and increasing extent, of the

Government; it commands a large support from the House

of Commons; and it has been received with marked com

mendation by the public press. Nothing but the strangest

apathy, the most short-sighted indecision on the part of

the profesion, can prevent its passing into law. This is

not likely to happen, for we are labouring under too many

grievances to let slip so fair an occasion of remedying

them. When the great bulk of the profession understand

that, in order to consummate their long cherished wishes,

they have nothing to do but to speak out loud and strong,

they will hardly fail to do so.

The provisions of the Bill have been so often discussed

that our readers must be well acquainted with them; but

we will once more give a sketch of the measure. All per

sons now in practice under any of the degrees and licenses in

force in any part of the Kingdom will be registered on pay

ment of the moderate fee of ?1, and will immediately ac

quire all the rights and privileges of registered prac

titioners, including the liberty to practise throughout the

whole of the Queen's dominions. Seldom, certainly, has

such a boon been purchased at so cheap a price. All can

didates for future admission to the profession must have

gone through a uniform course of study of five years' dura

tion, and have been examined by the Colleges of Physicians

and Surgeons of their respective countries, which Colleges

they will be compelled to join as members. Moreover,

every physician in future must have taken a University

medical degree; and every person applying for examination

at the Colleges must have either graduated at a University,

or must have passed an examination in general education

before a board created under the Bill. In order to pre

serve, as far as possible, uniformity of education, examina

tion, and fees, a regulating Council is established, composed

of delegates from the various Universities and Colleges, and

of eight representative members chosen by the whole body

of the profession. We had almost forgotten to add, though

it is one of the most important features in the Bill, that

the registration will know only of " physicians" and " sur

geons"; and that no third class, distasteful to the profession

however it might be named, will be either established or

perpetuated.

Such is an outline of the measure which the medical

men of this country now have within their grasp. A few

years since, the attainment of any such Bill would have

been thought an idle dream; and hopeful as is the prospect

now before us, let us not forget that all our exertions will

still be needed to insure its passing. Let us at once unite

as one man, and sink all petty differences. Let no un

worthy jealousies once more give Parliament an excuse to

say that medical reform cannot be carried, because medical

men cannot agree. Neither let us lend an ear to any evil

counsellors, who would instil into us doubts and fears, and

would tell us to hang back when the goal is full in view.

There are three ways in which medical reformers can

lend a helping hand, and we would urge all thme upon

them.

FIRST. Let every man, anxious to aid the Bill, commu

nicate with his medical brethren around him, and stir them

up to exertion.

SECONDLY. Let petitions be sent up to the House of

Commons forthwith, praying that the Bill pass into law.

They may be sent either to the M.P. for the locality, or to

Mr. Headlam. Petitions sent to a member of Parliament

pass free through the post.

THIRDLY. Let every effort be made to influence mem

bers of the House in favour of the Bill. This can be done

by private representations as well as by addresses from

public meetings. If these measures are promptly and energetically taken,

we shall soon congratulate the Association aud the profeE

sion on the existence, not of a Medical Reform Bill, but of

a MEDICAL REFORM ACT.

THE WEEK.

THE fatal list of Deaths from Poison, ushered in by the

Burdon tragedy, has since our last to be inscribed with an

other name. The suicide of Mr.Sadleir, M.P., on Hampstead

Heath, on Sunday morning, appears to have been preme

ditated in the coolest possible manner. The evidence given

at the inquest on Tuesday is conclusive on this point. The

unfortunate gentleman, it would appear, came home on the

Saturday evening with a determination never to be seen

again alive by those with whom he had business dealings.

We are enabled by the evidence to note the cunning by

which a man about to commit an evil deed seeks to ward

off suspicion, and to accomplish his end unnoted. The

order given to his butler to obtain the fatal potion comes

not as from himself, but from his groom, who had care of

his racing stud. " I don't know the quantity for it-but

Kenyon writes to me to buy one pound's worth." The

vessel in which he had determined to pour the poison the

suicide must have marked while at the evening meal, as

the man-servant twice attempted to remove the tea things,

but was prevented by his master. The silver cream jug

was necessary to his purpose; and if it had been re

moved, he would have been obliged to make special

inquiiry for some other portable vessel, and this would have

caused suspicion. The imagination can picture the lonely

midnight walk of the self-doomed man from Gloucester

Square, Hyde Park Gardens, to Hampstead Heath (if, in

deed, he did walk), and the still gloomier ramble on the

desolate heatb, which continued possibly until the gray of

the morning told him that he must make haste to accom

plish his purpose. The enormous quantity of the essential

oil of almonds which he took must have proved almost

instantly fatal, the slight indentations of the sod near his

heels indicating probably the spasmodic struggle which im

mediately preceded his death. What the verdict will be in

this melancholy case we do not know, but we must confes

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ISO ASOCIATION MEDICAL JODEAL. [Fzp 23, 186

w e ee o eo ee in the conduct of the deeae to justify the ordinary verdict under such circumstances, that

"Dceased committed suicide whilst in a state of tem

poay insauity"-unless, indeed, by "temporary insanity" is mneat that condition of the mind which induces a man to

commit a criminal act. The ease with which the unfortunate gentleman obtained

poisn enough to kill a whole parish, naturally struck the ooer, and called forth his condemnation. It is, in deed, a melancholy reflection that one of the most instanta neous poisons we have, can not only be obtained by anyone at the chemist's, but at the pastrycook's ! In order to put a stop to what we might term third class murders, or the poisoning cases that take place among the poor, the legis lature has directed that arsenic-the popular poison-shall be mixed with soot; but of the more subtle poisons, such as high class murderers and suicides are accustomed to use, it takes no notice. If it were possible to smile under such circumstances, the reader must smile when he reads the letterof Mr. Maitland the chemist, enjoining caution in the usc

of the drug he had forwarded-caution to the man who in tended to swallow the whole of it immediately as a death draught ! It is clear that all poisons of this virulent na ture must be withdrawn from public sale. The argument that some of them, such as the one under notice, are used in

our daily food, is worse than worthless, as it only proves that they are two-edged swords, capable of slaying in the hands of the innocent as well as ini those of the guilty.

A very sad mishap has taken place at the Garrison Hos pital, Chatham, by which a soldier of the 38th Regiment has lost his life. It appears that deceased and another man of the same regiment requiring a purge, Mr. Turner, the assistant-surgeon of the 75th, went into the surgery, and poured out, from what he thought to be the senna bottle, six ounces of laudanum, which was divided between the two men. One of the men immediately detected its different taste from senna: both, however, took it, and one within a couple of hours died, Mr. Bedwell, another asistant-surgeon, having been called to him in his ex tremity, and having failed to diagnose the fact of his having been poisoned by opium. The coroner's jury, we think, only did its duty in returning a verdict of Manslaughter aainst both surgeons in this instance. There appears to have been some excuse for Mr. Turner in adminis tering the opium by mistake, as the bottle was left out of its place by the hospital orderly; but no excuse can be sufficient to exonerate a medical man from pouring out the contents of a bottle without first ascertain ing its contents by looking at the label: and this, it appears from the evidence, he did. The other medical

man excuses his non-detection of the poison, some of which

was shown to him by the orderly, on the score of " having a bad cold": but surely his taste was left to him; and if not, the very fact of his attention having been drawn to the liquid should have suggested to him the propriety of ob taining the evidence of some one whose senses had not been obtused, even if the symptoms of poisoning by opium were not sufficient to cause him to suspect that that drug had been taken by mistake.

A correspondent of the Times, in a letter written from Mingrelia, as will be seen in our news columns, states that Colonel Simmons entirely neglects to mention among those who had distinguished themselves at the battle of the

Ingour, Surgeon Edwrds, of the modical staff, and his

assistant, Mr. Turner. There is no doubt that these gen

tlemen distinguished themselves by their coolness and

courage in attending to the wounded in a very exposed po

sition under fire; 80 much so, indeed, that Omar Pasha

personally requested Col. Simmons to give them his especial

thanks. At the same time, we are not disposed to join

in the ill-natured remarks made by the Mingrelian cor

respondent at the colonel's expense, as a reference to that

gallant soldier's despatch shows that it was written a few

hours after the battle, on the opposite side of the river to

that on which Messrs. Edwards and Turner were posted;

so that it was impossible that their services could have

been made sufficiently known to him. We have authority to state that, as soon as Col. Simmons was fully informed of

the value of their assistance, he wrote a letter, at the re

quest of the general in command, fully acknowledging their

able services in the handsomest manner; and such a letter, as

a permanent testimonial, is quite equal to any mention in a

despatch. That Colonel Simmons intended no discourtesy to these gentlemen, we feel convinced; neither do we think

they will miss promotion through any oversight or neglect

of his to report favourably of them to head quarters.

We have to congratulate the Association and the medical

profession this week on the second reading of the Medical

Reform Bill. With the exception of the feeble opposition of

Lord R. Grosvenor, who pleaded the cause of the quacks and

of the homoeopathists, the Bill passed through this stage of

its progress with great smoothness. The noble Lord, who

has been a prey to charlatanism all his life, urged the cause

of the latter with all his force. " Several hundred edu

cated medical practitioners," he informed the House, " were

practising hom4opathy in this country, who were as ho

nest, as scientific, and more aucces.ful thanw ihe others

(a laugh), but who would hereafter be liable to have their

name struck out of the register at the dictum of these bo

dies." It is clear from this that all the illegitimate prac

titioners, all the " obscene things" which now lurk under

the obstructions which stand in the way of legitimate medi

cine, are up in arms, and will range themselves under the

banners of this noble protector of quackery. In committee

the utmost efforts will be made by the enemies of the Bill

to demolish the clauses which form the armour of the le

gally qualified practitioner, therefore no exertion must be

spared to maintain them in all their integrity. Mr. Head

lam is prepared to concede any thing that is reasonable,

but we trust that he will not alter one word of his Bil

which builds up more firmly than before the barrier be

tween the scientific medical man and the quack. To enable

the promoter of the Bill to stand his ground, the profession must help him, and that immediately, and our advice to

every man who has its future welfare at heart, is to

PETITION! PETITION ! PETITIOR !

The Poor-Law movement is, we are glad to say, going on

vigorously. No less than FORTY-ONE unions, representing

upwards of two hundred Poor-Law surgeons, have already

sent in their adhesion to it, and others are daily joining.

We trust that ere long a Committee will be formed, and

subscriptions will be raised, in order to carry on the

struggle, as hitherto Mr. Grifn has had only his own ex

chequer to fall back upon.

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