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use of the new tourniquet. Mr. Hilton saw the patient aboutan hour after she had been removed to bed, and ordered hersome brandy, and twenty minims of laudanum, to counteractfaintness and nausea.

This tourniquet is furnished with three sets of rollers, instead oftwo, as in the ordinary Petit’s tourniquet. The arms of thelower platform are somewhat curved upwards, so as to preventpressure on the abdomen, on the one side, and the thigh on theother. In both upper and lower platforms, the arms of two ofthe sets are fixed, and so directed upwards and backwards, thatthe tapes easily embrace and hold on to the pelvis. The thirdset of arms are horizontally movable, so that the tape con-nected with them can be adjusted under the thigh, on theright or left side, as the occasion may require, brought upunder the glutaeai region, and buckled to the pelvis-strap atthe most convenient spot. The pad on which the tourniquetrests is to be placed on the artery as it passes over the ramus ofthe os pubis; and the instrument can be tightened in the ordi-nary way, until twenty-seven inches of the tape are taken up;so that any necessary amount of pressure can be made on thevessel.-This instrument, together with the drawings, models,and patterns, was made, under Mr. Hilton’s suggestion anddirection, at Mr. Biggs’s establishment, St. Thomas’s-street,Borough.

On making a longitudinal section of the amputated limb,some serous and synovial fluid escaped through the joint; theencephaloid disease appeared to have commenced in the inte-rior of the shaft of the femur, immediately above its junctionwith the condyles, and to have radiated from that point, im-plicating and displacing the surrounding structures. Nodistinct or separate fungoid tubercles could be detected inany of the surrounding textures, but the whole mass appearedto be continuous with the original seat of the disease in thefemur. The morbid growth had not extended to the interiorof the knee-joint, nor had it involved the epiphyses of thefemur; but it had passed up the medullary canal of the bone,so as to reach the lower part of the middle third of the femur,encroaching much higher internally than externally. The innerportion of the cylinder of the shaft was not destroyed beyondthe inferior part of the lower third, although its outer half wasoverlapped by the fungoid mass, which had broken through ’,the continuity of the bone a little above the epiphysis,spreading beneath the periosteum, and separating it fromthe bone. This circumstance probably explains the extremepain which the patient suffered, from the tension of the peri-osteum. The fungus, which had protruded through one ofthe punctured openings in the skin, was found to be a pro-longation of a large mass of fungoid growth, which had per-forated the periosteum, and thence had grown through thetrack made by the lancet before the patient’s admission intohospital. The periosteum, at the posterior part of the femur,although much distended, and pressed towards the poplitealspace, had not given way.For one month after the operation the patient progressed

very favourably by means of careful nursing, unremittedattention, and the cautious exhibition of tonics and stimulants.After this period, Mr. Hilton, considering that country airwould be very beneficial, and might ensure the completion of the

recovery, sent the patient to her native place, quite free fromindications of local or constitutional disease. We have sincebeen informed, that up to the end of June, 1852, being sixmonths after the operation, the patient was in excellenthealth, without any sign of a relapse.

This is extremely cheering,and much of this favourable resultis probablv owing to the soundness of the bone above theamputated point. A contrast to this circumstance will befound in Mr. Skey’s case, as given below. We shall make apoint of watching the further progress of Mr. Hilton’s patient;for if she remains well, the case will be greatly in support ofearly operations. ____

ST. BARTHOLOMEW’S HOSPITAL.

Encephaloid Disease of the Femur; Amputation; Small Fungusof the Bone soon after the operation; Death; Autopsy.

(Under the care of Mr. SKEY.)WE now proceed to the second case of the series. The

patient, a young man, about twenty-two years of age, wasadmitted in April, 1852. He had presented himself to Mr.Skey nearly four months before he was received into thehospital, complaining of pain in the lower and inner part ofthe left femur. The swelling was not considerable; it feltyielding and elastic; and as no indications of malignancy thenexisted, either in the patient himself or his family, the casewas looked upon as one of abscess, and treated accordingly.As, however, week after week passed on without any improve-ment being obtained, Mr. Skey modified the first-formedopinion, and thought that something more than abscess affectedthe patient.About six weeks before admission, an exploring needle was

introduced into the tumour, which had increased in size, andcaused the thigh to look about one-fourth larger than thecorresponding part on the right side. Blood was obtained bythe puncture, and the swelling felt now somewhat hard andtough. The same kind of fluid again escaped upon the tumourbeing a little while afterwards a second time punctured witha grooved needle. Very little doubt now existed as to themalignancy of the growth, and Mr. Skey took the opinion ofhis colleagues before resorting to the only means of reliefwhich could be had recourse to-viz., amputation.The question arose during the consultation, whether the

limb should be removed at the hip-joint or at some point ofthe thigh. Mr. Skey was rather inclined to propose the re-moval at the joint, but did not deceive himself as to theformidable nature of this operation; he laid due weighton the unfavourable results which had been recorded, andthought that the past clearly showed that we are hardlyjustified in resorting to it except where extension of the dis-ease to the head of the bone is extremely probable. Mr.Skey’s colleagues were likewise unfavourable to amputationat the coxo-femoral articulation; so that it was resolved totake off the thigh in the continuity of the shaft.The operation was accordingly performed on the 9th of

April, 1852, the patient having previously been narcotized bychloroform. Before proceeding to the removal of the limb,Mr. Skey made a puncture into the tumour, first with agrooved needle and then with a trocar, when a broken-downmass mixed with blood protruded. No doubt was now left onthe minds of the surgeons, and the amputation was forthwithperformed. The parts were immediately examined - theinvestigation being made very complete by a longitudinalsection of the bone and tumour. The affection was found tobe of the encephaloid kind, and to have sprung up betweenthe periosteum and the bone-the former being broken down,and the tumour invested by a fibrous envelope. The cancel-lous portion of the bone was considerably softened, and theoriginal laminæ of the cortical structure had been split in theprogress of the disease, but could be still distinguished.Towards the upper portion of the femur the cortical portionwas very hard, and became somewhat expanded and verythin below. The encephaloid growth was situated close to thecondyles, covering about the lower third of the femur and sur-rounding the whole circumference of the shaft; it presentedexactly the consistence and colour of brain, when it had beensubmitted to cleansing with cold water. On examiningthe bone it was discovered that the disease had clearly runup the medullary canal, and it thus became plain that themalignant growth might soon develop again in the stump.Mr. Skey stated the fact to the pupils assembled, and addedthat this circumstance strengthened the presumption that the

, disease would soon return; he was, however, not prepared to

proceed any further just now. If the affection were to recur,: . other measures, as for instance amputation at the hip-joint,

9

might be contemplated, if the patient’s strength would allowof the operation.The young man progressed pretty favourably for the first

week, when a small dark fungus was noticed to spring fromthe extremity of the divided femur; this gradually increasedto the size of a pigeon’s egg, and looked very much likecoagulated blood. The case from this time took an unfavour-able aspect, and the patient died on the 3rd of May, 1852,about three weeks after the operation.Ou a post-mortem examination it was found that the whole

shaft of the femur had completely lost its vitality, there beinga granulated purulent deposit in the medullary canal, withinterspersed spots of a deep black colour. Only half the headof the femur was deprived of life; the other half was still in ahighly congested state. In the cavity of the joint a consider-able effusion of pus existed, but no other purulent deposit orencephaloid growth was found in the other parts of theframe.

This case is well calculated to make us pause for a moment,to examine the question of amputation at the joint above theseat of the disease, or in the continuity of the shaft. It is plainthat at the time of the operation the femur, perhaps up to thehead, was extensively diseased, and that the only chance of res-cuing the patient from his perilous situation was the removalof the limb at the hip-joint. But this is really so terrible andfearful an operation, that the surgeon may well be excused fornot undertaking it without mature consideration. And doubtswill spring up still more forcibly, when he remembers thateven the hip-joint amputation does not completely ensure thepatient’s eventual safety, as the disease may, and, indeed, isvery likely, sooner or later, to seize upon some of the viscera.We do not, of course, pretend to solve the question; but wehope that by collecting facts, and by synthetically studyingthem, we may pave the way to the laying down of trustworthyrules for the guidance of surgeons, when they have to dealwith cases similar to the present.One point should in the meanwhile not be forgotten-

namely, that patients affected with encephaloid cancer have alonger average of life, after operation, than those who sufferfrom scirrhous cancer. Mr. Paget stated, in his excellentlectures delivered this year at the Royal College of Surgeons,that the general result of operations for encephaloid canceris more favourable than those for scirrhous cancer of thebreast. In the latter, the general average duration of life,after the patient’s first observation of the disease, is forty-nine months; the average life of those whose breasts are re-moved, and who survive the effects of the operation, is aboutforty-three months; and the average of life of those in whomthe disease is allowed to run its course is about fifty-fivemonths. In the former, (encephaloid cancer,) the averagelength of life, when the eye, testicle, breast, bones, or otherexternal organs are affected, is twenty-four months from thefirst notice of the disease; the average for those from whomthe primary disease is removed, and who do not die in conse-quence of the operation, is about thirty-four months; whilethe average of those with whom the disease is allowed to run itscourse is scarcely more than a year. These data were confirmedin a letter which Mr. Paget has addressed to the editor of thisjournal, (THE LANCET, vol. i. 1852, p. 603.) Thus it will beseen that operations offer, comparatively, a tolerable chance ofrelief in cases of encephaloid cancer. We shall now attempta short sketch of the third case of encephaloid disease of thefemur, from the notes kindly furnished by Mr. Blagden, latesurgical-registrar at St. George’s Hospital.

ST. GEORGE’S HOSPITAL.

Encephaloid Disease of the lower portion of the Femur ;Amputation ; Recovery.

(Under the care of Mr. HENRY CHARLES JOHNSON.)Jonx L--, aged twenty-three years, was admitted

January 15tb, 1851. under the care of Mr. Johnson. Thepatient presents a tumour which is very ill-defined, andsituited in the right popliteal space, as well as at each sideand in front of the lower extremity of the femur. The patellacannot be distinctly felt, being obscured bv the generalswelling at this part. The circumference of the tumour overthe largest point (which is directly on its centre) is twenty-two inches, and over the situation of the patella twenty-oneinches. The swelling is gradually lost above, on the front ofthe thigh, where great hardness can be felt; but there is nodistinct line of demarcation between the diseased and healthystructures. The leg is very cedematous, and pits on pressure.

An obscure sense of fluctuation is perceivable in the tumouritself, there is considerable tension of the skin, and slighttenderness when handled, but at other times a dull, achingpain is experienced. No pulsation can be detected in anypart of the swelling.The countenance of the patient is sallow and cachectic, with

an anxious expression; he is very weak, and has a nervous andrather irritable manner. Tongue dry; pulse rapid. Soonafter the commencement of the disease, leeches and blisterswere employed, which gave no relief. About a fortnightbefore his entrance into the hospital, the tumour had beenpunctured with a grooved needle, and afterwards an incisionmade, when a small quantity of blood escaped. The patientgives a very imperfect account of the origin and progress ofthe swelling; he states, however, that it has existed sixteenweeks only, so that its growth would appear to have been veryrapid.On the 23rd of January, Mr. Johnson removed the thigh

just below the trochanter, by the flap operation, the patientbeing insensible with chloroform. Free bleeding occurred,though the femoral artery was steadily compressed by anassistant, and the vessels were rapidjy tied.On examining the amputated limb, it was found that the

compact structure of the bone was exceedingly dense. Thetumour presented a brain-like appearance; some of thecysts of which it was composed were of large size, andcontained a considerable quantity of blood and serum. Thetumour was situated between the ham-string muscles; itextended upwards as far as about the lower fourth of thethigh, and then seemed to cease suddenly, contrary to theappearance which obtained while it was connected with therest of the limb. Below, the tumour reached to the inferiorpart of the popliteal space, and the cancelli of the lower ex-panded portion of the femur were soft, easily broken down,and filled with medullary matter. Where the bone becomesnarrower, a very small spot of the malignant deposit wasvisible in the interior of the shaft, not larger than the surfaceof a split pea.The progress of this patient created at one time considerable

alarm; attacks of haemorrhage occurred several times, whichsuccessively necessitated the application of ice, exposure tothe air, and the use of the tourniquet. The young man wasin the mean time becoming extremely weak, and no sign ofunion or healthy suppuration appeared in the stump, the dis-charge being of a thin and sanious character. Under thesecircumstances, Mr. Johnson had recourse to emollient andastringent applications, careful bandaging of the stump, sup-port, and, above all, to large doses of chlorate of potash, in thefollowing form :-Chlorate of potash, one scruple; spirit ofchloric aether, fifteen minims; cinnamon water, one ounce: tobe taken three times a day. The state of the patient con-tinued very precarious for one month after the operation,when the stump began to heal kindly; all the ligatures weregradually removed, and the health improved considerably.Forty-eight days after the amputation the wound was quitecicatrized; the patient went into the country, and we areglad to say that lie has been seen more than a twelvemonthafter his discharge, when he was found to have grown stout,and there were no symptoms of a recurrence of the dis-ease.

When encephaloid cancer attacks the upper part of thefemur, and patients apply for relief when the affection hasmade considerable progress towards the ilium, there can beno doubt about the propriety of waiving any kind of opera-tion, and resorting to palliative means only. There are atpresent, at the London and St. Bartholomew’s Hospitals re-spectively, two victims of this dreadful disease, where theupper part of the femur and the pelvis present tumours of anencephaloid kind, about the size of three adult heads. Veshall just give a few details of these cases, as affording usefulfacts bearing upon the history of the disease.

LONDON HOSPITAL.

Encephaloid disease of the Pelvis and upper part of the Femur.

(Under the care of Mr. JOHN ADAMS.)WILLIAM D-, aged eighteen, was admitted into the

Prince of Wales’s ward, under the care of Mr. Adams,Nov. 18, 1851. The patient has been residing in BetlinalGreen, working as a hemp and flax dresser, and enjoyedexcellent health until about four months before his admis-sion ; his mother, however, died of tumours on her neckand below the knee, and his brothers and sisters are issues of