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to set up by the operation increased action in the vessels of theparts, and to take care that the circulation in the limb shouldbe free and unimpeded during the process of restoration.

In the ordinary treatment of fractured humerus, splints anda circular bandage are applied. the arm placed in a sling, andthe patient allowed to go about. That the free circulation ofblood is in this way impeded, is shown by the frequently moreor less oedematous state of the forearm towards night, and Ithink the non-union of this bone especially, which so oftenoccurs, is thus explained.A few years ago the following case occurred to me :—A man

by a cart accident fractured the middle third of his thigh. ftwas put up with short splints and a tail bandage, and he wasplaced on his back in bed. At first he appeared to be going onvery well; there was no spasmodic muscular action, and theposition of the limb was straight and good. In about a fort-night, however, the foot became slightly cedematous, and,although everything about the thigh was perfectly loose, thecedema continued during another week or nine days, and therewas not the least consolidation of the broken bone. I thenfor the first time found that under the bed-the bedstead beinga turn-up one-there was a transverse wooden rail, the sharpedge of which projected upwards, and corresponded to the

popliteal space of the injured limb, the vessels of which hadbeen compressed by it, and infiltration of the foot and anklethereby produced. I immediately had the man placed on abed on the floor. In a day or two afterwards the swelling haddisappeared, and firm union of the fracture soon took place.

I adduce this case as an illustration of the bad effects of im-peded circulation. There can be little doubt that, had thecause continued some time longer, this would have been a caseof unuuited fracture.To constantly keeping in view the principle of maintaining

free circulation in the limb, I attribute the circumstance that,during a practice of many years amongst the mining popula-tion of this neighbourhood, one peculiarly exposed to thecauses of fracture (I have had at the same time under treat-ment as many as nine broken thighs), I have never in my ownpractice had a case of failure of union, except in the neck ofthe femur. In consultation, occasional cases of non-union havecome under my notice. In one of them-of the tibia, thefibula being entire--an operation similar to the one describedwas bad recourse to, with an equally fortunate result.

In fracture of the limbs I have always used the simplest ap-pliances, and adopted such positions as would favour ratherthan impede free circulation, in preference to mechanical appa-ratus, however ingenious, some of the results of the applicationof which, when presented to me, have been anything but satis-factory.In conclusion, I quite disclaim any originality of idea or

practice in thus briefly detailing some of my experience on asubject which, from its frequency of occurrence, must alwaysbe an interesting one.January, 1859.

----

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum etdissectionum historias, tam aliorum proprias, collectas habere et inter se com-parare.—MORGAGNI. De Sed. et Caus. Morb., lib. 14. Proœmium.

KING’S COLLEGE HOSPITAL.

MEDULLARY TUMOUR OF THE CLAVICLE; SUCCESSFUL

REMOVAL, WITH THE OUTER HALF OF THE BONE.

(Under the care of Mr. BOWMAN.)ALTHOUGH cancer has a predilection to attack certain bones,

sush as the lower end of the femur, the upper end of the tibia,and the lower jaw, yet we find it occasionally affecting otherparts of the skeleton, where its presence might not be suspected.The clavicle is one of the latter. Operative measures in this

situation, for partial or complete excision, are attended withgreater risk than elsewhere, from the important relations ofthe neighbouring structures.We to-day place upon record a good example, in which the

outer half of the affected clavicle was extirpated, followed byan excellent recovery. The disease proved to be the medullaryform of carcinoma. A case almost precisely similar to thisappears in a previous " Mirror" (THE LANCET, vol. ii. 1852,p. 34). It occurred in a delicate girl of fifteen, a patient inGuy’s Hospital, in whom the outer half of the collar-bone wasinvolved in medullary disease. This part of the bone was re-moved by Mr. Bransby Cooper. The girl, however, survivedthe operation b-.it a few weeks, as the disease had extended tvthe scapula and neighbouring parts. We may likewise referto a cancerous tumour, the size of a shadc1oek, involving theclavicle of a man aged fifty-nine, under J’r. 1farsden’s care, atthe Cancer Hospital. (See the " Mirror" of May 30th, 1857.)The disease was too extensive for operative interference, andthe man succumbed.The whole of this bone has been removed successfully by

Mott and Warren, for the same disease, in the United States.Partial or complete excision has been practised by Davie, Syme,Fergusson, Erichsen, Potter, and others, with success, fornecrosis or some other disease. The whole of the clavicle wasexcised by 1>1:1’. Potter, at the Newcaatle-on-Tyne Infirmary,for necrosis, in 1848. (THE LANCET, Yol. i. 1-49, p. 392.)Mr. Travers was, however, the first surgeon who successfullyremoved the entire bone in this country. (THE LANCET, vol. L1852, p. 52.)For the notes of the following case, we are indebted to Mr.

J. Walters, house-surseou to the hospital.J. T-- aged sixteen, admitted November 20th. iShe states

that she always enjoyed good health till eighteen months ago,when she began to suffer pain in the outer third of the leftclavicle. at which place a small hard nodule appeared duringthe next six month,;. During the following two months thenodule increased to the size of a walnut. In July of last yearshe became an inmate of a London hospital, where the tumourwas removed. Six weeks before admission, when the formerwound had nearly closed, she noticed a swelling close to thesite of the original one. This increased in size very rapidly.

I P,i-6,.seitt condition.-The patien is tall and rather spare, withdark hair and eyes; the complexion is rather sallow. Attachedto the outer half of the left clavicle by a firm base is a tumourof an ovoid shape, having a purple tinge ; in some places theskin over it is brown and smooth, as if having cicatrized, Itis firm and elastic to the touch, and the tingers placed upon itshow considerable pulsation, but no bruit is audible. Thedimensions of the tumour are, from back to front, four inches;from side to side, four inches and a half. In front it occupiesthe outer half of the clavicle; behind it extends nearly to thespine of the scapula, separated from it by a deep sulcus; ex-ternally it extends as far as the acromio-clavicular joint. Thetumour moves readily with every movement of the shoulder,and the action of the joint is perfect. The glands in the neckand axilla are not at all enlarged.

Dec. 4th.-The tumour has increased to the following dimen-sions:- Back to front, five inches; side to side, four inches anda half. It is more prominent than on admission, and bleedowhen scratched. On the outer side are three or four darkmalignant-looking nodules, which seem about to give way. Thesuperficial veins on the left side of the chest are enlarged. Inthe afternoon, chloroform having been administered by Dr-Anstie, the tumour was removed in the following manner:-Asmall transverse incision was made over the centre of the

clavicle, at the inner side of the tumour. The skin was thendissected up for three-quarters of an inch towards the sternum.The clavicle was then sawn through; the divided end wasseized with strong forceps, and raised, and an incision was car-ried along the front of the tumour, as far as the acromion pro-cess, through the healthy skin. The knife was then carrieddeeply in the same line, so as to divide the subclavius muscleand the clavicular ligaments. The circuit of the tumour wasnow completed by an incision carried behind it, and the wholemass easily removed. The operation was terminated by dis-secting off various detached portions of the tumour from thetissues underneath; in doing this the trapezius muscle and theparts at the base of the posterior triangle were laid bare. Thescaleni muscles and the subclavian vessels remained covered bythe fascia. Six or eight ligatures were applied, and one suturewas placed over the divided end of the clavicle. The tumourwas found to consist of soft medullary substance, of a reddish-grey colour, containing numerous spiculae of bone; at its innerside the tumour was partially covered by an expansion of the

133

compact tissue of the clavicle. The enter end of the claviclewas not involved in the disease. Under the microscope, all theelements of a rapidly-growing malignant tumour were apparent- lamely, 1--tr),e mother cells, and fusiform cells, containingseveral nuclei, granules, &e. The mass consisted almost en-

tirely of cells, a very small quantity of intercellular substancebeing present. t.

5th. -His passed a good night, but has vomited several times.Pulse 12S. The left arm is kept raised on a pillow. Orderedsix ounces of brandy in the twenty-four hours; ammonia ineffervescence; beef-tea, &c.13th.--The wound is covered with healthy and exuberant

ranulatiol1s; the sickness still continues at intervals; there isan erythematous blush over the chest, extending as far as theright breast. Pulse 120. Ordered an enema, containing tengrains of quinine.ISth.-The erythema has disappeared, and the vomiting en-

tirely ceased ; the edges of the wound look healthy ; at thecentre the granulations are raised, and have a purple colonr, asif taking on a malignant action; they were touched freely withnitrate of silver.2‘Ith.-The malignant appearance in the centre of the wound

has entirely gone, and the wound has contracted to half its iformer size. There is an inflamed gland in the right axilla, Iwhich threatens to suppurate. Health improving every day.Jan. 12th.-The wound is contracted to the size of half-a-

crown, and looks perfectly healthy. The abscess in the rightaxilla was opened a week ago, and has now ceased to discharge.She is able to walk about, and while doing so, is ordered tokeep her arm in a sling. She now takes citrate of iron withquinine, five grains three times a day.22nd.-The wound has contracted to the sise of a pin’s head;

there is no appearance of any fresh growth around, and thereare no enlarged glands in the neighbourhood. She is able toraise her arm above her head, and executes various movementswith her left arm as readily as with the right. There is no per-ceptible drop in the left shoulder, the only apparent deformitybeing a slight sinking-in of the tissues where the tumour wassituated.

Since the operation, the patient’s health has very much im-proved; she has gained flesh considerably, and has lost herformer sallow look. She still keeps the left arm in a bling,placed so as to support the elbow.

CHARING-CROSS HOSPITAL.

TRAUMATIC TETANUS FROM A LACERATED WOUND OF THE

FOREARM AND RADIAL ARTERY ; TREATMENT BY BEL-LADONNA AND CHLOROFORM ; FATAL RESULT.

(Under the care of Mr. CANTON.)WE publish this week brief details of a case of acute trau-

matic tetanus, treated by the external application of belladonnaand the internal use of chloroform, but the result was unfa-vourable. Although recoveries from this disease are rare, yetunder various plans of treatment, which have been tried withinthe past fifteen months in our hospitals, cures have beeneffected. These we will take an early opportunity of advertingto. The remedies which proved successful were, nicotine, bel-ladonna, opium, Indian hemp, stimulants, &c. At the DI’ead-

nought hospital, of three cases of traumatic and one of idio-pathic tetanus, which came under the treatment of Mr. Corner,the resident medical officer, belladonna was given internally intwo, with marked benefit in one, and great relief to the localsymptoms in both ; it was applied also externally in the formof plaster. Two of the patients died. In the first of the twccases that recovered (a boy of thirteen, who got chilled byleaving off his flannel drawers, which resulte(l in tetanus), thEbelladonna plaster was used, with full doses of morphine whenrequired, his strength being well supported by wine, and hisbowels freely purged. The other case was one of fractureof the ulna, with some contusion of the arm. The patient wa,purged, his arm lightly bandaged, and a twenty-minim dose 0:tincture of conium given every three hours. The latter was smild example of the disease.The notes of the following case were taken by Mr. Holtor

Arnold, house-surgeon to the hospital :-Charles a--, aged fifty-three, a gardener, of temperat<

habits, but of nervous and irritable temperament, was admittedon Sunday, Jan. 9th. He had fallen through a green-house

and received a lacerated wound of the lower third of the fore-arm, extending for about an inch over and implicating theradial artery. He lost a large quantity of blood, as the arterywas not tied. Symptoms of tetanus showed themselves onFriday, 7th, and on Sunday he was sent to the hospital.On admission he was examined, and rigid contraction of the

jaw and the flexor muscles of the neck found to exist. Hecould not open his mouth more than an eighth of an inch, butwas able to articulate ; pulse 80, regular, but compressible andjerking. Urine was examined, and found normal. The woundwas dressed, and an opiate administered. Copious enemata ofcastor oil and turpentine and warm water were given, andseemed to give great relief. The muscles affected were smearedwith extract of belladonna, and a poultice saturated withwatery solution of opium applied to the wound. Brandy andbeef-tea were given freely ; chloroform was administered everyhour in doses of ten minims, which were gradually increased tofifteen, and afterwards to twenty. He appeared much relievedafter each dose, but spasms came on with violence. Thewounded arm became quite rigid, and only relaxed when thedose of chloroform was administered. Opiates were given, butvery little rest was obtained, on account of the frequency andviolence of the spasms.

Jan. 12th.-Two A.M.: The patient had a short nap, at theclose of which he was attacked with a sudden and violentspasm, and died from asphyxia, produced by the contraction ofthe muscles of expiration.

CLINICAL RECORDS.

LONG-STANDING NECROSIS OF THE TROCHANTER.

WE have refrained from the consideration of the affection ofnecrosis, unless it has happened to be unusually interestingfrom its peculiar seat, or from its possessing features differingsomewhat from those met with in the ordinary class of cases.On the 19th January, an exceptional case was submitted totreatment at St. Mary’s Hospital, by Mr. Ure. The patientwas a man fifty-four years of age, who was kicked by a horseover his right hip forty years ago, and has nearly all that timesuffered from the effects of necrosis of the upper part of theshaft of the femur, and more recently of the trochanter majorof that bone. During the last two months he has sufferedmuch from the state of his thigh, which is riddled with sinusesand fistulous openings. When under chloroform, Mr. Ure slitup five of these sinuses, and came down upon the diseasedbone, nearly all of which was removed by the aid of a gougeand cutting forceps. Many loose fragments were detached. Alarge cavity existed in the great trochanter, which was care-fully scooped out. The entire wound was now filled withoiled lint, so that free suppuration might become established,and the parts heal up from the bottom. As respects the extentof the disease, together with its long duration, it is one of theseverest cases which has come under our notice for some time.The amount of suffering endured by this patient has greatlytold on his constitution, and has induced an appearance of age.

N&AElig;VUS IN THE ORBIT AND ON THE LEG.

IT is somewhat unusual to meet with a nsevus within theorbit, and in such a situation it is more likely to assume thecharacters of an aneurism by anastomoses; or perhaps the vas-cular tumour may possess the characters of both in a mixed

degree. Something of this kind was present in an infant whohas been submitted to operation several times at St. George’sHospital, during the past few months, by Mr. Pollock. Theexternal characters were those of a naevus, which extendedfrom the outer canthus of the right orbit backwards, pressingagainst the back part of the eyeball, and thrusting it forwards,giving the child a very peculiar appearance. The operationsconsisted of obliterating the deeper vessels by means of red-hotneedles, and superficially by drawing up folds of the nsevuswith forceps, and tying them with ligatures. As the superficialportions were thus destroyed, the deeper parts seemed to pressforward, and were then similarly treated. When last we sawthe child, the cure appeared complete, and the eyeball hadresumed its natural position. There can be no doubt that ifthe child were permitted to grow up to adult age, a verydangerous aneurism by anastomoses would be formed, whichby timely treatment is got rid of with comparative facility.

I In Howard’s work on the Eye, all the various modes of

treatment employed in vascular tumours of the orbit and eye-