tion in the constitutional conditions you will find enumerated in surgical works. Age, pregnancy, debility, paralysis, may be dismissed from consideration; and, as to the influence of syphilis, you have only to visit any one of our accident wards, and you will find evidence enough to prove that it is no obstacle to the repair of fractures. Nor has the seat of the injury, including the relation to the nutrient vessel, anything to do with the non-union of the broken bone (with the exceptions I will presently name); although the delay in union may be thus explained, and great care in the treatment may be thus in some cases called for.

It must be admitted, however, that some conditions, chiefly of a local character, absolutely prevent a broken bone from being mended. Such fractures as result from cancerous infiltration of bone are practically irremediable; so also are those which involve a bone atrophied from dis

ease.

There was an instance of this some four years ago in the hospital wards, in the case of a man who had the lower end of the femur hollowed out into a large abscess-like cavity, the wall of which, thin as parchment, had cracked across at the condyles, and would not repair. Then, again, there are cases in which foreign bodies interpose between the fractured ends, of which Sir James Earle's case of a portion of deltoid muscle getting between the broken pieces of a humerus, and the occasional wedging of a piece of broken and subsequently necrosed bone between the fractured ends, are instances; and, lastly, other cases in which it is difficult, sometimes impossible, to keep the broken portions in apposition, as in some cases of fracture at the neck of the thigh-bone, and in most instances of transverse fracture of the patella, which is an injury almost invariably repaired by fibrous tissue. But, if we allow for these cases, we have remaining some instances of non-union which do not admit of explanation on such local grounds, and which are generally referred after a time to air, to age, sometimes to youth, or to some of those constitutional conditions which I have ventured to tell you cannot be credited with the occurrence of non-union; although one, perhaps

namely, debility-may be responsible for delayed repair. From such cases, a certain number may be deducted which, without question, have been badly treated by inexperienced or untutored persons-fractures occurring on board ship, and the like; and then, of those which remain, it is within my experience that they are examples either of delay in the process of repair, as from the obstruction of veins, or of delay through the interposition of certain mechanical difficulties; and in these cases a favourable result may be generally obtained by treatment. For convenience in mentioning them, these latter may be referred to as fractures with certain displacements of bone, fractures extending obliquely through bone, and fractures in the vicinity of, not extending into, joints; and in each of these delayed union may be traced to the fact that sufficient time has not been allowed in the first instance for the firm union of the bones; for in each a longer time is needed than is thought necessary in the case of other, or, as they may be termed, ordinary fractures.

In

The fractures with displacement may be illustrated by an example taken from the femur. Quite recently, a youth has been under treatment in my wards with a fracture of the femur, which had been treated on board ship, and which had united very slowly, with shortening and a considerable bend outwards of the shaft. of the bone. The patient was himself conscious of the weakness, as he called it, of the limb, when he first began to move about; and he was aware that the bending of the bone had increased at this time, which was before his admission here. fact, the union, which might have been sufficiently good to support the weight of the body if the two parts of the femur had united so as to preserve the proper axis of the limb, and to allow the shaft to bear naturally the pressure from above, was insufficiently firm to resist the same pressure when brought to bear upon a shaft in which the fracture was joined at an angle; and the uniting tissue, under these circumstances, yielded, and in time, it is not unlikely, had he persisted in moving about, would have given way altogether, and we should have had a case of what would be

been said that the patient had moved about before the union was firm; or that, from some cause or other, firm union had been delayed; whereas the union was probably as good as in ordinary cases suffices to support the body, but in this instance was overstrained by the weight pressing at an angle instead of in the proper long axis of the thigh-bone. This case, then, represents a class in which longer time should be given for the consolidation of the repair than is needed when the long axis of the shaft can be properly preserved during the progress of union.

It is a somewhat similar condition which exists in cases of oblique fracture. The tibia-the bone of the leg which sustains the weight of the body-is often fractured so that two very oblique surfaces are left in contact. These specimens from the museum are examples of this injury. When such a hurt has to be treated, I always allow an extra fortnight-say six weeks in all-before the apparatus is disturbed and the patient allowed to put his foot to the ground; and for this reason: In these fractures, the whole weight of the man falls on and strains the new material, which has joined the fracture, in such a fashion that there is always a tendency for the upper fragment to glide off, or to be launched, as it were, from the lower; the latter part of the bone giving little if any support, whilst in a transverse fracture, or a fracture only slightly oblique, it largely assists in bearing the superincumbent weight. Imperceptibly, it may be, in such a case, the union gives way; pain is felt by the patient; and, on re-examining the limb, repair is found to be incomplete. All the cases of non-union of the bones of the leg which have been brought under my notice have been instances of oblique fracture; and every now and then, in these wards, we have found it necessary to put up afresh a fracture of this kind, upon which a patient has been allowed too soon to bear his weight.

Of fractures near the joint, that of the humerus in its lower third is, perhaps, of all the one most often followed by non-union. Various explanations have

a

ticular failure of bony union; but certainly in one case we could trace it to this, and I suspect, in most cases, it is in this direction that the cause is to be looked for. A fracture of the humerus is put up; and the forearm, at least for convenience, is placed at a right angle, and slung. As the case progresses, question is raised as to the possibility of the elbow being stiff. The hand and forearm are flexed and extended a little, and the joint is said to move freely. If this examination be repeated, you must not be surprised if you find, when in due course you come to examine the fracture, that it has not united. The elbow being for the time somewhat stiff from disuse, it was not the joint which moved, but the fracture which was rocked in flexion and extension, as it easily may be when you act on it with the great leverage given you by the forearm, and so was hindered from becoming firm. I never knew an elbow-joint to be anything but temporarily stiff after a fracture of the humerus not extending into the joint; so that in these cases there is no excuse for handling the forearm. The arm should be left perfectly at rest during the entire process of repair; and no movement of the elbow should be permitted until it is certain that the bone is firm.

If you remember these as typical of certain classes of cases, you will be prepared to prevent the occurrence of nonunion in most of the comparatively few cases in which special care will be called for. Of another class-that of failure of bony union from the difficulty of keeping the separate fragments in juxtaposition, as after transverse fracture of the patella-you may learn from this patient, recently discharged from Harley Ward, who has sustained an injury of this nature, that it it is not impossible to obtain osseous union even under what at first may appear unfavourable circumstances, if only you give time for the process to complete itself, and take care that in the meanwhile no strain is allowed to stretch the fibrous tissue which at first unites the pieces of the broken bone.-Brit. Med. Journ., Nov. 30, 1872.

HOSPITAL NOTES AND GLEANINGS.

Medullary Cancer cured by the Arsenical Mucilage Treatment.-The following is a good example of the kind of cases for which the arsenical mucilage treatment, introduced by Dr. MARSDEN, Surgeon to the Cancer Hospital, is most preferred. The tumour being a medullary cancer of comparatively small size, situated on the exterior of the body, and not penetrating deeply into the tissues at its base, all the conditions as to nature, size, situation, and connections, combined to favour the use of the remedy, and the result was as successful as could be desired.

The tumour grew from the skin over the trapezius muscle near its anterior edge, about midway between the head and shoulder. It was quite circular at its base, with a diameter of nearly an inch, and rose about three-quarters of an inch above the level of the skin at its highest point in the centre-closely resembling, in fact, a large strawberry in size and shape, as well as in colour, the whole surface having a red fleshy appearance, cut up by fissures of various depths, and thickly covered by large round granulations. It was so closely encircled by skin, that it overlapped a little at the edges; the skin, however, around the base was not otherwise perceptibly altered except in colour, there being here simply an areola two or three lines in breadth, of a purplish hue, in the direction of which the veins were visibly increased and enlarged. It bled on the slightest touch, and, being extremely sensitive, was the source of constant pain. The history of the case showed that, about three years before, a small tumour appeared at the site of the present one, and, on being lanced, discharged blood freely. It continued to bleed more or less occasionally until the wound closed, when, in consequence of its increase and the pain arising from it, it was excised; soon afterwards it reformed, and was again excised, but still kept on growing; and, at the time of the patient's admission into the hospital, on February 22, 1872, presented the characters described. The patient was

moderately healthy woman, 42 years of age.

As the patient was in tolerably good health, there was no occasion for delay on that ground; and accordingly, on February 23, the arsenical paste (consisting of arsenious acid and mucilage of acacia, in the proportion of two drachms of the acid to one drachm of the mucilage, made into a thick paste) was laid over the whole surface of the tumour, and covered with cuttings of lint in the usual way. In three days, the diseased mass was quite movable, and a sulcus lay between it and the skin, leaving it attached only at a small portion of the base. Bread-and-water poultices were then applied and changed every three or four hours; and on the fourth day (February 27) the whole mass came away in a lump, leaving in place of the tumour a conical cavity with slightly indurated edges. The wound was poulticed in the same way as before for a few days, and then dressed with weak spirit lotion. Healthy granulations sprung up over the whole surface of the cavity, and by the 23d of March its size was reduced to about a third, and the induration of the edges was much less. On April 9, the wound was quite healed, the induration had entirely disappeared, and the only indication of the former disease left was the cicatrix and an increased vascularity of the skin around it. The patient remains quite well up to the present date (October 8).

Another case with a tumour, as near as possible in resemblance to the above, situated on the chest near the middle line immediately above the breast, is at present in the hospital under the care of Mr. Porter, for which the same method of treatment is being employed. This patient is a feeble old woman, 70 years of age, and has had the paste twice applied; the first application, although it appeared to remove the whole of the disease, being followed by a slight return of the growth when the wound was nearly healed. It is now, after the second application, progressing favourably, without any symptom of a return of the disease. Dr. Crombie, the house surgeon, remarks

that, during his residence at the hospital, he has seen other cases of recovery by this treatment continuing well at considerable intervals afterwards, although in one instance the disease removed from the cheek had appeared on the tongue about three years afterwards. Brit. Med. Journal, Nov. 2, 1872.

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Fracture of the Skull in Broca's Region; Paralysis of the Right Side; Loss of Power of Speech; Death; Autopsy. Although no single explanation seems sufficient to account for all cases of aphasia, still it must be granted that in the vast majority of the permanent cases there is paralysis of the right side, which is associated with some disease or injury of the posterior part of the third left frontal convolution of the brain. That this does not always obtain is fully proved by cases recorded by Vulpian, Charcot, and even Broca himself, in which there was aphasia but no disease of this portion of the brain, or disease of this part and no aphasia. Further, Trousseau gives a case in which there was well-marked aphasia with left hemiplegia. Nevertheless the following case is of interest, as showing a direct injury to this part of the brain followed by complete aphasia and subsequent paralysis of the right side. It is doubtful, however, whether the large effusion of blood was directly due to the injury, or took place secondarily from an injured or diseased vessel. It is difficult to believe that so extensive a destruction of brainsubstance by the extravasated blood should not declare itself by paralysis of the right side till so many hours had elapsed. It is probable that the injury gave rise in the first instance to only a slight effusion of blood, but that this gradually increased till it assumed the dimensions found at the autopsy.

J. H—————, a workman employed at the London Hospital, in a quarrel with one of his fellows, was struck on the left temple with the leg of an iron bedstead at about 5 P.M. The case was supposed to be one of scalp wound, and the patient was allowed to go home. It was not ascertained at this time that there was any affection of the speech. About three

hours after the accident he was seen walking to his home, a distance of two miles from the hospital. On reaching home his wife, alarmed at the sight of the bandages, asked him what had happened, but, being unable to speak, he made signs for a pencil and paper. Before getting these he touched his head with his left hand (he was a left-handed man), pointed to the leg of a bedstead, and then clenched his hand as if striking a blow, which an intelligent neighbour interpreted to mean that he had received a blow on the head with the leg of a bedstead, to which he nodded assent. He then went to bed, using both his hands in undressing. A medical man being called in, it was directed that he should be brought to the hospital. To this the patient agreed, but in dressing it was noticed that he could not use his right hand, and, in walking to the cab, that he dragged his right foot. On arriving at the hospital he was quite insensible. Mr. McCarthy was then sent for, and saw him for the first time at 11 P.M., when he was unconscious and breathing stertorously; the right side paralyzed and the left convulsed; left eye intolerant of light, the right insensible to touch and light. At the bottom of the wound was a depressed fracture, at the anterior part of the left parietal bone. The history of the case pointing to gradually increasing compression of the brain on the left side, probably from effusing blood, the wound was explored, and some overhanging bone removed with a trephine, and the depressed portion raised and withdrawn, with some splinters that had been driven under the sound portion of the parietal bone. There was a free flow, uncontrolled by pressure on the carotid, of dark-coloured blood, but no wound of the dura mater was detected. A firm compress and bandage were then applied.

Next morning the man was quite conscious and in so far improved. The convulsions on the left side had ceased. The right side was still paralyzed as to motion, but when his hand or foot was irritated he used the left hand or foot to protect himself. He perfectly understood all that was said to him, and readily at