M 8^? ;• i\>i(i:^^':^'? WALTER JARVIS BARLOW HISTORY OF MEDICINE COLLECTION BIOMEDICAL LIBRARY, UNIVERSITY OF CALIFORNIA AT LOS ANGELES N..' i^-'v? ' 5X-- 7 •''>•-> DESCRIPTIVE CATALOGUE ANATOMICAL AND PATHOLOGICAL SPECIMENS IN THE MUSEUM OF THE IRo^al College of Surgeons of IE^in^)urgb CHARLES W. CATHCART CONSERVATOR : FELLOW OF THE COLLEGE Vol. I— the skeleton AND ORGANS OF MOTION PRINTED AT THE EDINBURGH PRESS, 9 & 11 YOUNG STREET PUBLISHED BY JAMES THIX, EDINBURGH 1893 PRICE SEVEN SHILLINGS AND SIXPENCE PREFACE. ]4isTT:ivj UJ The Museum of the Koyal College of Surgeons of Edinburgh dates from about the end of last century. Although the specimens were only formally entered in the General Catalogue about 1807, many of those afterwards added had been collected before that time. Under the fostering care of Eobert Knox, W. M'Gilhvray, John Goodsir, H. Lee, W. Sanders, J. Bell Pettigrew, and E. Blair Cunynghame, the general collection has steadily increased by donations of individual specimens and prepara- tions, but it has also been enriched from time to time by collections formed by private persons. Of these, the most important is the "Bell Collection," which will be afterwards referred to, but many others must also be mentioned. Thus there were the Collections formed by one of the College Professors of Surgery, an office now obsolete, Professor John Thomson, and those formed by Messrs James Eussell, after- wards Professor in the University of Edinburgh, and Eobert Allan ; the Series of Urinary and Biliary Calculi collected by Dr William Newbigging; the admirable Dental Collection formed by Mr Nasmyth ; and the preparations, casts, and instruments illustrating Ophthalmic Surgery collected by Mr William Walker. In more recent years Dr C. E. Underbill presented his Midwifery Museum to the College, and Dr vi Preface. Thomas Keith, on leaving Edinburgh for London, handed over to the Conservator a Series of Tumours illustrating his work in Abdominal Surgery. Dr Bryan C. Waller has presented to the College a collection of Specimens illustrating Medical Pathology, which he purchased from Dr Eutherford Haldane. Besides these, there have been added other smaller collec- tions, to which it does not seem necessary to refer in detail. The " Bell Collection " * was purchased from Mr, afterwards * The following account of the Bell Museum was published in 1819, while it was still in Great Windmill Street, London. Although many additions were made to it in the subsequent six years, the account is valuable as a record of the mode of formation of the Museum :-— " The formation of this Museum may be divided into three periods — tliat formed by Mr Wilson, that formed by Mr Bell, and the addition made during the last seven years. " Mr Bell's original Collection consisted of preparations, both of Natural and Morbid Anatomy. It was particularly valuable in Quicksilver Preparations; in Preparations of the Lymphatics; in Diseased Bones; in Diseases of the Bladder and Urethra; and in Models of Diseased Viscera. " The Collection of Mr Wilson was remarkable for the exquisitely neat manner in which the preparations had been dissected and preserved. Its value was principally in the complete Series of Preparations, exhibiting the Minute Structure, and arranged so as to correspond with the Lectures. These must always form an important part of the Present Museum from their intrinsic value, as well as from the Maker, who learned his art under the celebiated Mr Cruickshank (the fine Collection of Mr Cruickshank was bought by the Empress of Russia), the Colleague of Dr Hunter. " By the arrangement betwixt Mr Wilson and Mr Bell, Mr Wilson's Preparations became the j^roperty of the latter, and the two Collections were united. Since that period, that is, in the last seven years, great additions have been made (not less than one-third of the whole). To the pupils of that period, it is not necessary to say that this has been done principally through the labours of Mr Shaw. Mr Shaw was a pupil of Mr Bell's at a very early age, and has continued making Preparations under him for eleven years." Preface,. v Sir Charles. Bell in 1825, and is now incorporated in the general collection, of which it forms a very valuable part. Most of the specimens referred to in Sir Charles Bell's published works are thus to be found in this Museum. In this way it happens that besides the actual specimens which his keen interest in all physiological and pathological questions led him to preserve, we have in many instances the advantage of a description of their clinical history from his graphic pen, and sketches of their clinical appearances from his still more graphic pencil. The "Barclay Collection," chiefly of Human and Comparative Anatomy Specimens, forms a part of the Museum of the Royal College of Surgeons of Edinburgh, but by the deed of presentation it is kept separate from the rest and stands in a Hall by itself. It contains a few Pathological Specimens, but these unfortunately cannot be used to enrich the General Collec- tion, although in one or two instances casts of the specimens Jiave been made for that purpose. The former printed Catalogue of the Museum was compiled by Dr M'Gillivray, afterwards Professor of Zoology in Aberdeen, and was published in 1836. It included all the Specimens, Casts, and Drawings then in the Museum illustrating Pathology, but none of those illustrating Human or Com- parative Anatomy. The present Catalogue has been very carefully drawn up with the express purpose of making the Collection practically useful to students and members of the Medical Profession. An erroneous view of pathological Museums — altogether viii Preface. foreign to that of our Museum founders — is unfortunately common, namely, that they are collections of mere pathological curiosities, the study of which is something quite different from that of practical Medicine and Surgery. It is needless to say that this is an entire misconception, for a properly arranged Museum obviously offers an insight into the varieties and con- sequences of injury, and into the natural history of disease, which clinical study alone cannot supply. The object held in view, therefore, in classifying, arranging, and describing the specimens for the present Volume, has been to bring them into line with clinical work. This has required so much re-arrangement and re-description of the specimens in the Museum, that the present is essentially a new Catalogue rather than a second edition of the old one. Various illustrations of General Pathology form the first Series. The specimens it contains illustrate certain aspects of Hypertrophy and Atrophy, of Inflammation, Degeneration, and Repair, which could not otherwise be so well compared. Every effort, however, has been made to limit it, and it does not include Tumours, for reasons that will be afterwards explained. In the Specimens illustrating special Pathology the larger Classes have been formed upon the usual Physiological basis, and are such as " the Skeleton and Organs of Motion," the affections of which occupy the present volume ; also " the Ali- mentary Canal," " the Respiratory System," and others, which will be taken up in a subsequent volume or volumes. Within the first Class there have been formed three Divi- sions— i.e. (1) the Bones and Joints; (2) Muscles and Tendons, Preface. ix Synovial Sheaths, Burs?e, and Fasciae, and Connective Tissue ; and (3) " the Limbs as a whole." The specimens thus included have been formed into ten Series (see general Analysis). The Series are numbered consecutively throughout the divisions of the first Class, and it is intended to carry on the numbers of the succeeding Series continuously through the Classes and Divi- sions which have yet to follow. Within each Series, however, the numbers of the individual Specimens begin anew. In the Bell Collection, a Series of specimens illustrating the normal structure of each organ preceded those illustrating its abnormal conditions. This method was discarded when the previous Catalogue was drawn up, but has now been re - adopted. The same principle has moreover been carried out among the individual Pathological specimens, where a still closer proximity of the normal and abnormal seemed advantageous. Nothing need be said about the mode of subdividing the first five Series, but of that employed in the sixth — "Diseases of Bone" — some explanation seems advisable, especially as, with certain modifications, it has been applied to the Series which follow. Under the general title " Diseases of Bone " four main groups have been recognised, i.e. I. Abnormalities in growth or development, which are chiefly, of course, congenital ; II. Altera- tions due to local or general affections of Nutrition; III. Inflammatory Diseases; and IV. Tumours or New Growths. The subdivisions of the first and second of these groups may be sufficiently studied in the General Analysis ; but of those of the third group— -i.e.. Inflammations — a short explanation may not be out of place. The view of Inflammation which X Preface. underlies the classiiication here adopted, is that enunciated by Lister* in 1858, and emphasised afterwards by Cohnheim, Burdon Sanderson, and others, namely, that Inflammation is not so much a disease in itself as a consequence of inter- ference with the vitality of the tissues. Causation of Inflammation has therefore been chosen as the basis of primary subdivision, and the modes of interference with vitality, or causes of Inflammation, are thus the distinguishing features of the larger groups. Although it is difficult to conceive how much we may still have to learn on this subject, the knowledge acquired in recent years seems sufficient to justify the plan adopted, even should it require to be afterwards modified. As it stands, this plan carries with it at least two distinct advantages. Museum specimens are by its means arranged in accordance with present clinical and pathological knowledge. This is obvious, but in addition the confusion which has so frequently arisen from a " cross classification " has been avoided. Such headings as " Necrosis," " Periostitis," and " Syphilis " are commonly used as co-ordinate yet distinct subdivisions of bone disease ; but as the first indicates " result," the second " locality," and the third " causation," the groups are not mutually exclusive, and uncertainty and con- fusion is the necessary consequence. The place for " result " as a basis of subdivision of diseased bones seems to be within each of the larger groups formed upon the basis of " causa- tion," to which it thus becomes of subsidiary importance. In the case of Syphilitic diseases of bone, those of the * Philosophical Transactions, 1858. Preface. xi Skull have been kept separate from those of the rest of the skeleton ; but with this exception, " locality " has not been used as a basis of subdivision in this Series. Never- theless, an examination of the groups formed will show that " locality " has accompanied the " results " due to the various " causes " in a remarkably close way. Thus there are various forms of necrosis, caries, and enlargement, depending upon different causes, and showing corresponding differences, 1)ut also locating themselves mainly in different bones, or forms of bone tissue. " Locality " might therefore have been used as subsidiary to " result " through all the groups of bone disease had it seemed necessary. Among joints, on the other hand, " locality " has been considered of more importance, and has been used to divide and subdivide the specimens ranged under the various causes of Inflammation. In every case we must remember that "the division must be founded upon one principle or basis," -i.e., " some quality or circumstance," which, in order to be taken as the basis of sub-division, "must be present with some and absent with others, or must vary with the different species comprehended in the genus."* What that basis is will depend upon the general character of the specimens, the state of knowledoe at the time the classification is made, O and the judgment of the classifier. It is true that some forms of cross-classification still remain, but while they seem inevitable, they are less likely to confuse than those now excluded. Thus, for example, many diseases of joints affect chiefly the bones ; compound fracture may lead to * Jevons' "Elementary Lessons in Lo^ic,"' 1893, p. 105. xii Preface. disease of bone; and, again, many diseases of stumps are really only diseases of the bone. In such cases the specimens have been placed in what seemed the more important group, and representative specimens, or cross references, have been put in the other group to which they may be considered also to belong. The subdivision of the fourth group, Tumours, or Now (xrowths, is based upon the view that they are essentially modi- fications of growth, and not merely responses to irritation ; further, that they take their type from the tissue from which they arise, and that they vary in their rate of growth and degree of malignancy. Consequently, no attempt has been made to form a general group of " Tumours," but instead, each Pathological Series has its department for " Tumours," just as it has for " Inflammations " of various kinds. The order in which the individual specimens have been arranged within the groups has been based upon the following general principles. Among Fractures the larger groups have, as is usual, been based upon " locality," i.e., the bone, or special part of it which has been broken. Within the groups thus formed, the speci- mens have been classed as recent, and of old standing, and the latter again as united or ununited. Other groups of injuries have been similarly treated. Among Malformations, the lesser degrees have been placed before those more pronounced. In Inflammations, early stages of disease have been placed before those more advanced, in order to illustrate the successive phases of the particular malady. These have been followed. Preface. xiii when possible, by others, illustrating spontaneous cure, and lastly, by those which show the results of operations. Among Tumours a study of the clinical history and naked- eye appearances seems a better foundation for their arrangement in a Museum than their microscopical characters. Consequently, the Tumours of any particular tissue or organ will be found to range from the simple, well-developed, slow-growing forms to those which grow quickly, are undefined in structure, and are clinically malignant. The microscopical characters of any specimen have been looked upon as an adjunct to its descrip- tion rather than as an essential element in its classification. It follows, as a natural consequence from the above method of arrangement, that all the contents of the Museum which represent a certain degree of deformity, stage of disease, or kind of tumour have been grouped together. Formerly, in this as in many other Museums, spirit preparations were placed in one part of the Museum, dried preparations in another, casts in a third, and drawings in a fourth. Now, they are all classed together in the Catalogue when they belong to the same or to similar specimens. Where, owing to variations in shape and size, some of the individual members of a group could not be conveniently placed upon the shelves with the rest, every effort has been made to place them so close to the others that the student can refer to them without loss either of time, or of a sense of the general continuity. In many cases published drawings of the patients from whom the specimens were taken have been copied by photography and placed beside the specimens they illustrate. xiv Preface. Each specimen is furnished with its Series -number, fol- lowed in smaller type by its own number within the Series. These numbers are of course repeated in the Catalogue. The plan of giving to the description of each specimen a general heading in bold type has been adopted from Sir George Humphry's Catalogue of the Cambridge Museum and from the revised edition of the Catalogue of Guy's Hospital Museum. This heading is followed in the same paragraph by a state- ment of what the specimen is, and by an account of how it has been prepared and mounted. Next comes the clinical history in small print. Every effort has been made to obtain these histories of the specimens. The various manuscript Catalogues contain many, which were either not used at all, or only briefly abstracted in the previous Catalogue. These have now been largely drawn upon. In addition, every available clue has been followed that promised to lead to a clinical account of any of the specimens, whether in the old Infirmary records, or in the published writings of the donors of the specimens. It is to be regretted that this has been possible with only a limited number of the specimens, and it may be assumed that where no clinical history is given, none has been accessible to the present conservator. In natural sequence after this paragraph, follow, in larger type, the descriptions of the speci- mens in their recent state (when obtainable), and as they are permanently to be seen in the Museum. Last of all are added such comments as seemed desirable. Before the donor's name, the Manuscript Catalogue number has been given to facilitate further reference if required. G.C. Preface. xv means the General Manuscript Catalogue, in which all speci- mens presented to the Museum are entered, unless they have formed part of a collection provided with a separate Catalogue. B.C. refers to the MS. Catalogue of the "Bell Collection;" and W.C. refers to the MS. Wilson Catalogue. Although the specimens in the " "Wilson " Collection were transferred to the " Bell," it has been considered better in the case of important pathological specimens to refer when possible to the original source of information. A considerable number of the speci- mens described in the former printed Catalogue had not been entered in any other. This is specially true of those presented by Professor John Thomson. They are referred to now as F. P. C. (Former Printed Catalogue), followed by the corre- sponding number. When the date of the presentation of any specimen to the Museum is not stated, an approximation to the date may be obtained from the following general statement as to the entries in the General Manuscript Catalogue : — The numbers had reached to 805 in 1826, to 1216 in 1830, to 2272 in 1842, to 2415 in 1857, to 2467 in 1865, and to 2764 in 1886. The Conservator wishes here to record his thanks to the Presidents and Council of the College and to the Members of the Museum Committee for the hearty encouragement which they have given to him throughout his work for the present volume. He would be very ungrateful, too, if he were to forget to mention another to whom his thanks are especially due. Tentative arrangements and re-arrangements of the specimens have, of course, been required ; taking down and re-mounting xvi Preface. the specimens for careful examination has also been frequent. In all this the Conservator feels it but right to say that his work has been greatly facilitated by the manipulative skill and ingenuity, by the exactness and conscientious care, and perhaps, most of all, by the unfailing patience and goodwill, of his able assistant Mr George Eeid. GENERAL ANALYSIS GENEEAL PATHOLOGY. Series 1.— General Pathology. Hypertrophy — Physiological, i.e. associated with increased function ..... Compensatory, i.e. from artificially increased demand on function .... Irritative, i.e. from irritation of various kinds . From altered nutritive conditions From unknown causes .... From absence of usual modes of removal . No. ill Series. Pages. 1-3 1, 2 4-8 2-4 9-12 4,5 13 5 14, 15 5, 6 16, 17 6, 7 Atrophy— Physiological — from old age From diminished function From various causes 18 7 19-22 7 23-31 8-10 Inflammation — Various illustrations of 32-41 10-12 Repair of Injuries — Healing by first intention Healing by second intention 42-47 48-51 13, 14 14, 15 Degenerations and Infiltrations 52-60 15-17 18 General Analysis, SPECIAL ANATOMY AND PATHOLOGY. CLASS I. — THE SKELETON AND OKGANS OF MOTION. DIVISION I.— BONES AND JOINTS. Series 2.— Structure and Development of Bone. structure of bone . Process of development in general Development in particular — The Skeleton as a whole The Skull The Spine The Thorax The Upper Limb The Pelvis and Lower Limb Structure of Foot . Comparative Anatomy No. ill Series. 1-9 10-17 Pages. 18-20 20, 21 18-22 21, 22 23-33 22-24 34-40 24, 25 41-46 25, 26 47-68 26-31 69-104 31-37 105-109 37, 38 110-112 38 Series 3.— Injuries of Bone. Fractures of the Skull — Fissured Fractures Comminuted fractures chiefly localised Comminuted fractures with fissures leading from them . Compound fractures Healed fractures Gunshot fractures Sabre wounds . Fractures of the Lower Jaw Fractures of the Spine Fractures of the Thorax . Fractures of the Clavicle . Fractures of the Scapula . Fractures of the Humerus Fractures of the Radius and Ulna Gunshot fractures of the Upper Limb Fracture of the Pelvis Fractures of the Neck of the Femur — intra capsular . ■ 1-15 39-45 16-29 45-50 30-37 50-53 38-45 54-57 46, 47 57, 58 48-57 58-62 58-60 62, 63 61-63 63, 64 64-91 64-79 92-94 79, 80 95-101 80-82 102, 103 82 104-126 82-90 127-143 90-96 144-164 96-102 165 103 166-184 103-109 General Analysis. 19 Series 3. — Injuries of Bone — Continued. Fractures of the Neck of the Femur — -extra- capsular .... Fractures through the Trochanters Fractures of the Shaft — recent and uniting Fractures of the Shaft— united . Fractures of the Shaft — un-uuited Fractures involving the Knee-joint Fractures of the Patella . Fractures of the Tibia into the Knee-joint Fractures of the Tibia — recent and uniting Forms of fracture and mode of union Fractures of Tibia and Fibula — united — A. From direct violence B. From indirect violence Fractures of the Tibia — united Fractures of the Tibia — un-united Fractures of the Fibula Fractures into the Ankle-joint — a. Chiefly involving the Tibia 6. Chiefly involving the Fibula Fractures of the Tarsal bones Gunshot fractures of the lower limb — (a) Chiefly from "Waterloo . {b) From the Crimea (c) From the American War (1861-65) Comjiarative Pathology of Fractures . Series 4.— Structure of Joints Series 5.— Injuries of Joints. Dislocations of the upper limb Dislocations of the lower limb . Series 6.— Diseases of Bone. I. Abnormalities in Growth or Development a. From deficiency in development . /). From excess in development II. Changes produced by Conditions affecting the Nutrition of Bone — A. Changes in old age No. in Series Pages. . 185-205 110-118 . 206-209 119, 120 . 210-219 120-124 . 220-241 124-131 . 242, 243 131 . 244-249 132-135 . 250-259 135-137 . 260-262 137, 138 . 263-269 138-140 . 270-277 140-143 . 278-285 143-146 . N 286-290 146, 147 291-297 147-149 . 298, 299 149, 150 . 300-303 150, 151 . 304-310 151-153 . 311-318 153-156 . 319-321 156, 157 . 322-377 157-176 37S 176 . 379-390 177-182 . 391-399 182-184 1-38 185-190 1-12 191-195 13-24 195-198 1-4 199, 200 1-3 199-200 4 200 510 200-202 20 General Analysis. Series 6. — Diseases of Bone — Continued. No. in Series. Pages. B. Changes from various local conditions . 11-16 202-^05 C. Changes from affections of the central nervous system .... 17-21 205-208 D. Alterations due to conditions apparently constitutional but more or less obscure — (a) Rickets .... 22-51 208-220 (6) Osteo-malacia . . . 52-55 221-224 (c) Ostitis Deformans . . . 56-58 224, 225 III. Inflammatory Changes in Bone. 1. Changes in bone due to inflammation in the neighbouring soft parts . . . 59-77 225-232 2. Inflammation of bone produced by mechanical or chemical irritation 3. Inflammation of bone produced by pus-forming organisms ..... A. Where the organisms have reached the bone through the circulation . a. Where important changes have not had time to develop b. Where the chief changes are in the form of rarefaction and absorption c. Where the chief changes are in tlie form of enlargement d. Where the changes in the bone tissue have resulted in an abscess c. Where the chief changes are in the form of necrosis .... (a) Where the dead piece has been in process of separation . . 103-114 246-251 {h) Where the dead piece has become loose, but has remained in position 115-133 252-259 (c) Sequestra, or dead pieces which have been separated . . . 134-155 259-265 (rf) Repair after separation of sequestra 156, 157 265, 266 B. Where the organisms have reached the bone through wounds a. Disease in bone secondary to ulcers . 158-162 266-268 b. Where the chief changes are in the form of rarefaction .... 163-170 268-270 78-81 232-234 82-87 2.34-238 88-93 238-240 94-102a. 240-246 General Analysis. 21 Series 6. — Diseases of Bone — Continued. No. in Series. Pages. c. Where the chief changes are in the form of enlargement . . . 171,172 270,271 d. Where the chief changes are in the form ofnecrosis .... (a) Where the dead piece has been in process of separation . . 173-185 271-275 {b) Where the dead piece has become loose, but has remained in position 186-194 275-278 (c) Sequestra, or dead pieces which have been separated . . . 195-201 278-280 4. Inflammation of bone produced by the Tubercle Bacillus — a. Where the chief changes are in the form of rarefaction . . . . 202-208 280-282 b. Where the chief changes are in the form of absorption and enlargement . 209-217 282-285 c. Where the chief changes are in the form of necrosis with absorption and enlargement .... 218-228 285-288 5. Where the Inflammation has been due to the combined action of the tubercle bacillus and of pus-forming organisms . . 229-236 289-292 Healed Tubercular Disease {sec also under Tuberculosisof Joints and Spine, Series 7). 236 292 6. Inflammation of bone due to syphilis — A. The Skull— a. Where tlie chief changes are in the form of rarefaction (a) Where the process of rarefaction has been advancing . . . 237-245 292-296 (b) Where the process of rarefaction has been healing . . . 246-250 296-298 h. Where the chief changes are in the form of enlargement .... 251 298 c. Where the chief changes are in the form ofnecrosis .... 252-266 299-307 d. Sequestra due to syphilis after separation 266-281 308-314 B. The Skeleton— n. Where the chief changes are in the form of enlargement .... 282-337 314-330 7. Inflammation of bone due to syphilis com- plicated by sepsis .... 338-345 331-334 22 General Analysis. Series 6. — Diseases of Bone — Cmitinued. 8. Combined effects of syphilis and rickets 9. Inflammation of bone due to actino-m3'^cosis . 10. Inflammation of bone due to the mycetoma fungus ..... IV. Tumours of Buxe. A. Cartilaginous tumours ranging from simple to malignant .... B. Osseous and connective tissue tumour ranging from simple to malignant a. From the periosteum and bone h. Central Tumours Sarcoma following fracture Sarcoma invading bone C. Cancer (secondary) of bone . Tumours of the lower jaw Tumours of the upper jaw and facial bones The Skull — I. Abnormalities in growth or development II. Changes due to alterations in nutrition and growth — a. Old age ..... h. Local conditions affecting nutrition or growth .... c. Changes associated with alterations in nervous system — (1) Hydrocephalus (2) Idiocy .... d. Changes due to obscure conditions Series 7.— Diseases of Joints. I. Abnormalities in growth or development II. Changes due to alterations in nutrition. III. Inflammation of Joints — 1. Where the inflammation has been due to pus- forraing organisms. a. Where the organisms have reached the joint through tlie circulation . h. Where the organisms have reached the joint through wounds 2. Where the inflammation has been caused by the Tubercle Bacillus. No. in Series. Pages. 346, 347 334 348 335 349-353 335-338 354-372 338-350 373-427 351-374 428-453 374-386 454-462 386-390 463 390-392 464-476 392-396 477-489 396-401 490-515 402-413 516-520 414, 415 521, 522 415, 416 523-528 416, 417 529-536 418-420 537 421 538-547 421-423 1 424 2, 3 424, 425 4-8 425-428 9-15 428-431 General Analysis. 23 Series 7. — Diseases of Joints — Continued. Knee-joint. a. Changes primarily in synovial membrane b. Changes primarily in the bone, or apjiar- ently so . . c. Specimens illustrating spontaneous cure . d. Results of operations for tubercular disease Sacra-Iliac Joint Hip-Joint. a. Changes primarily or chiefly in synovial membrane .... b. Changes primarily or chiefly in bone Ankle-joint. a. Changes primarily or chiefly in synovial membrane .... b. Changes primarily or chiefly in tlie bone . Joints of the Foot. a. Changes primarily or chiefly in the synov- ial membrane b. Changes primarily or chiefly in the bone . Shoulder-Joint Elboiv-Joint. a. Changes primarily or chiefly in the synov- ial membrane .... b. Changes primarily or chiefly in the bone. c. Spontaneous cure after tubercular disease d. Result of operation for tubercular disease Wrist-Joint. a. Changes primarily or chiefly in synovial membrane .... b. Changes primarily or chiefly in the bone . c. Spontaneous cure after tubercular disease d. Results of operations for tubercular disease 3. Changes due to "arthritis deformans" — Knee-joint Sacro-iliac-joint Ui2J-joint Shoulder -joint Mborc-joint . Joints of the hand No. in Series. Pages. 16-63 431, 450 64-68 450-45'2 69-89 452-461 90-95 461-463 96 463 97-100 463-465 101-109 465-468 110-115 468-471 116-120 471, 472 121 122-130 131 472 473-476 476 132-137 476-478 138-141 478-481 143, 144 481 145 481 146, 147 482 148-152 482-484 153 484 154, 155 485 156-165 485-489 166 489 167-182 489-498 183-190 498-502 191-197 503-506 198 506 24 General Analysis. Series 7. — Diseases of Joints — Continued. No. in Series. Pages. 4. Changes due to rheumatism . . . 199-201 506, 507 5. Changes due to miscellaneous organisms — Gonococcus ..... 202 507 Anchylosis from conditions the nature of which is obscure ..... 203, 204 508 IV. New Growths involving Joints . . . 205-207 508,509 DX8EASES OF THE Si'INAL COLUMN — I. Abnormalities in Growth or Development II. Changes produced by Conditions affecting Nutri- tion and Growth .... Lateral curvature .... 208-221 510-516 III. Inflammatory diseases — 1. Where the inflammation is due to the action of pus-forming organisms 2. Where the inflammation is due to the action of the tubercle bacillus, i.e. "tubercular disease of the spine," "Pott's Disease," etc. A. Tubercular deposits without marked alteration of the curves . . 222-226 516-519 B. Where there has been distinct loss of substance leading to alteration of the curves . . . 227-244 519-530 C. Spontaneous cure more or less com- plete .... 245-256 530-534 3. Where the inflammation is due to the poison of syphilis 4. ' ' Arthritis deformans " affecting the spine IV. New Growths affecting the Spine DIVISION II.~AIUSCLES AND TENDONS, SYNOVIAL SHEATHS, BURSJE, FASCI.E, AND CONNECTIVE TISSUE. Series 8.— Stpuetupe and Arrangement, of Muscles and Tendons, Synovial Sheaths, Bursae, Faseise, and Connective Tissue ..... 1-11 539-541 257 534 258-265 535, 536 266 537, 538 General Analysis. 25 Series 9.— Injuries and Diseases, of Muscles and Tendons, Synovial Sheaths, Bursse, Fasciae and Connective Tissue- No. in Series, Muscles and Tendons — Injuries ..... 1 542 Diseases ..... I. Abnormalities in Growth or Development II. Changes produced by Conditions affecting Nutrition and Growth Changes from affections of the nervous system 2, 3 542, 543 Changes from constitutional or other con- ditions more or less obscure . . 4-6 543, 544 III. Inflammatory Diseases — Abscess in muscle .... 7 544 IV. New Growths ..... Synovial Sheaths — Injuries ........ Diseases. I. Abnormalities, and II. Changes produced by Alterations in Nutrition and Growth III. Inflammatory Diseases — 1. Inflammation due to mechanical injury 2. Inflammation due to pus-forming organisms . 3. Inflammation due to the tubercle bacillus . 8-12 545, 546 Btjrs^ — Injuries Diseases. I. Abnormalities in Growth or Development II. Changes produced by Alterations in Nutrition Growth . . . . . 13, 14 547 III. Inflammatory Diseases — a. Where the inflammation has been due to mechanical injury . . . 15 548 6. Where the inflammation has been due to pus-forming organisms c. Where the inflammation has been due to the tubercle bacillus. . . . 16-19 548, 549 IV. New Growth 20 549 26 General Analysis. Series 9. — Injuries and Diseases of Muscles, etc. — Continued. FASciiE AND Connective Tissue I^ew Growths Fatty tumours .... Fibrous tumours Fibro-sarcomatous tumours Sarcomatous tumours . Ptecurrent fibroid tumours Dissemination of sarcoma Melanotic sarcomata Chondro-sarcoma Jso. in Scries Pages. 21-28 550-552 29-32 552, 553 33, 34 553, 554 35-57 554-561 58-65 562-566 66-68 567 69-72 568 73 569 DIVISION III— TEE LIMBS AS A WHOLE. Series 10.— Development of the Limbs Series 11.— Injuries, Deformities, and Diseases of the Limbs as a Whole. Recent Injuries . . . . . Results of Injuries . . . . . Deformities of the Limrs 1,2 1-3 4-8 570 571, 572 572, 573 Upfcr Limb, a. From deficiency in development h. From excess in development 9-14 15, 16 574, 575 575, 576 Lower Li ml. a. From deficiency in development h. From excess in development Distortions in Position and Shape — Lower Limb. Talipes .... Flat Foot .... Miscellaneous deformities Upper Limh. Dupuytren's Contraction . Miscellaneous deformities 17-21 22, 23 576, 577 577, 578 24-40 578-582 41-44 582, 583 45-51 583-586 52-56 586, 587 57-59 588 General Analysis. 27 Series 11. — Injuries, Deformities, and Diseases of tlie Limbs as a Whole— Continued. No. ill Series. Pages Gangrene — a. Dvy senile gangrene b. Moist senile gangrene c. Other forms of gangrene Stumps after Amputation — a. Anatomy . . . • . b. Pathology .... c. Forms of Stumps 60-69 588-591 70-74 591-595 75-81 595-597 82-93 598-602 94-99 602-604 )0-104 604-605 GENERAL PATHOLOGY. SERIES I. GENERAL PATHOLOGY. HYPEETEOPHY. PHYSIOLOGICAL, i.e. ASSOCIATED WITH INCKEASED FUNCTION. 1. 1. Enlargrement of Mamma in a Preg-nant Woman.— Sections of two mammary glands — in spirit — to show the difference between the suckling and the non-suckling condition of that organ. The larger portion is from the breast of a woman who died after an operation for extra-uterine pregnancy at full time. The smaller and more fibrous-looking portion is from the breast of a non-pregnant woman, aged about 26 years. The enlargement in the pregnant mamma is due to the extra development of the acini forming the epithelial portion of the breast. This is perceptible not only on the surface, but also on the section, where the masses of epithelium show of an opaque yellow colour, surrounded by fibrous tissue. G. C. 3164 and 3101a. Presented hj Charles W. Cathcart, F.R.C.S.E., 1889. 1. 2. Enlarg-ement of Bone corresponding- to Muscular Development. — Two specimens of the right human scapula ; to illustrate the bony growth which corresponds to greater muscular development. G. C. 3136. 2 General Pathology. 1. 3. Skeleton of a Mole {Talpa vulgaris). — The bones of the fore limb are developed greatly in excess of those of the hind limb. This difference corresponds to the greater use made of the fore limbs in burrowing. The development of muscle corresponds to that of the bones. G. C. 3137. €OMPENSATOEY, %.C. FROM ARTIFICIALLY INCREASED DEMAND ON FUNCTION. 1. 4. Hypertrophy of Bladder Wall associated with old- standing' Stricture of the Urethra. — Preparation of bladder, part of penis, and urethra. The bladder and prostatic portion of urethra are opened from above. The prostatic abscess, and the membranous and spongy parts of the urethra, are opened from below. The patient, who had suffered from stricture for some years, had been in the habit of passing soft bougies on himself. Two days before his death he had sent for a surgeon, "who found him sinking" (probably from extravasation of urine). Above the stricture, which was very narrow and plugged by a calculus, the urethral mucous membrane is dilated, ulcerated, and covered with "calculous" (phosphatic) deposit. The prostate has become an abscess cavity communicating with the urethra. A thick white rod shows where the urine had escaped into the cellular tissue of the penis and scrotum. Smaller white rods indicate the ureters. B. C. xiv. 1. M. 41. 1. 5. Hypertrophy of Fibula from Strain. — Plaster cast of a remarkable specimen of ununited fracture of the tibia which is in the Barclay Collection. There has been an ununited fracture of the tibia, with a false joint. The fibula is much bent, and is at the same time greatly thickened, especially at the concavity, and at the convexity of the curve. These changes have evidently been the result of an increased strain on the bone, owing to the ununited fracture of the tibia. G. C. 3080. Hypertrophy. 3 1. 6. Thickening" of the Capsular Ligament of the Hip- joint from Strain. — Upper end of the right femur of an old person, — in spirit — showing an ununited fracture of the neck, and changes consequent thereon. The soft parts are cleared off, excepting the ligamentous attachment round the hip. The patient, a man aged 70 years, lived for fifteen months after receipt of an intra-capsular fracture of the neck of the femur. The neck of the bone has been greatly absorbed, and the broken surfaces are smoothed and slightly hollowed out. Bands of newly-formed fibrous tissue unite the detached head to the capsule and to the neck. The thickening of the capsule is very manifest. G. C. 1478. Presented by Prof. W. R. Turner and Alexander Watson, F.R.C.S.E., 1834. 1. 7. Thickening" of Epidermis from Pressure and Friction. —Longitudinal section of the left foot of a man, — in spirit — showing changes in the epithelium of the heel and ball of the toes. Owing to a severe compound fracture of the Tibia in his youth, the patient had for 30 years been unable to walk on his heel. He had therefore borne his weight on the fore part of his foot. The thickness of the epidermis below the balls of the toes is much greater than that below the heel. This condition is the reverse of what is found when the tread is normal. G. C. 3130. Presented by A. G. Miller, F.R.C.S.E., 1889. 1, 8. Hypertrophy of Kidney. — This preparation consists of bladder, a sound kidney on one side, and a shrivelled one on the other, from an adult man, — in spirit. The bladder is laid open from above. The patient died of some complaint unconnected with the kidneys, and their condition was only accidentally observed at the post-mortem examination. The right kidney is not much larger than the prostate gland, and is calcareous and shrivelled, this most probably being General Fatliology. the result of tubercular disease, spontaneously cured. The leffc kidney is about twice the size of an ordinary one, but seems to be normal in structure. No doubt the enlargement has followed the increased demand upon its functions from the destruction of the other kidney. G. C. 3229. Presented hy Harvey Littlejohn, F.R.C.S.E., 1890. FROM IRRITATION OF VARIOUS KINDS. 1. 9. Periostitic Bone Formation near Septic Necrosis. — Lower portion of the stump of a femur, in which there has been necrosis — macerated and dried. The patient, a girl ast. 15 years, had suffered amputation through the thigh some time before the specimen was obtained. The lower end of the bone shows one distinct necrosis, with a smaller spicule of necrosis near it. The end of the medullary cavity has been closed in with bone, and a complete shell of periosteal bone surrounds the original shaft. This shell is thick at its lower end and along the anterior aspect of the femur. G. C. 3138. 1. 10. Thickening- of Ribs from Empyema.— Section of two ribs, with a portion of a greatly thickened pleura, showing the above changes. In consequence of prolonged empyema the pleura has been greatly thickeiied, and along Avith this a considerable growth of bone has taken place on the surface of the ribs next the pleura. G. C. 3074. Presented hy Charles W. Cathcart, F.R.C.S.E., 1889. For other similar changes in bone, see Series 6. 1. 11. Increased Growth of Hair over a Tubercular Joint. — Elliptical piece of skin removed from the front of the knee Hypertroijhy. 5 of a child, with patella and part of diseased synovial membrane. When the joint was excised, the hairs on the surface were three or four times larger than those of the corresponding part on the opposite side. G. C. 3367. Presented by k. G. Millek, F.R.C.S.E., 1892. 1. 12. Hypertrophy of Bone due to Mechanical Irritation. — Bones of the fore-limb of a fox, in which a wire loop has been embedded by the formation of new bone round it. The specimen was obtained from the leg of an adult fox, which had been recently killed. ' ' The skin was perfectly liealed up, and there was no mark exter- nally, except a narrow line of yellow hair round the black part of the paw, showing Avhere the skin had been cut by the wire. It is evident that the animal had got his foot entangled in a snare set for rabbits, that he had first drawn it so tight as to cut through the flesh to the bone, and then had succeeded in breaking the wire " (letter from donor). From the comparative smoothness of the new bone, the condition must have been one of long standing. No doubt at first there must have been much inflammation, and that probably septic. G. C. 2400 Presented by T. Macpheksox Grant, Esq., 1854. FROM ALTERED NUTRITIVE CONDITIONS. 1. 13. Hypertrophy of Subcutaneous Fat on Anterior Abdominal Wall. — Section of the anterior abdominal wall of an elderly woman, near the linea alba. The specimen shows a very large hypertrophy of subcu- taneous fat, and slightly, also, of subperitoneal fat, while the skin and fascial structures remain quite thin. G. C. 3077. Presented by Chakles W. Cathcart, F.R.C.S.E., 1889. FROM UNKNOWN CAUSES. 1. 14. Congenital Hypertrophy of Finger.— Cast in glycerine General Patliology. and gelatine, of a case of congenital hypertrophy of the hand and fore-arm of an infant girl aged 20 months showing enlarge- ment of the middle finger. The finger had been unusually large at birth, and had afterwards increased still more out of proportion to the others. It was amputated by Dr Joseph Bell the day after the cast was made. The finger is about one-third longer and three or four times thicker than the others. The end of the finger is about the same girth as the infant's wrist. G. C. 2731. Presented by Charles "W. Cathcart, F.R.C.S.E., 1884. 1. 15. Cong'enital Hypertrophy of Finger.— The amputated finger, of which the foregoing specimen is a cast. The preparation is in spirit, and shows the enlargement to be chiefly due to increase in the subcutaneous fat. G. C. 2730. Presented by Joseph Bell, F.R.C.S.E., 1884. FKOM ABSEXCE OF USUAL MODES OF EEMOVAL. 1. 1 6. Hoof enlarged from Disuse. — Foot of a Red Deer— dried — showing an enlargement of the hoof and dew claws. Owing to an injury of its leg, the animal had for several years been unable to put its foot to the ground, and in con- sequence the hoof had not been worn against the rocks and heather. G. C. 3078. Presented by Charles M'Hardie, Gillie, Bracmar, 1889. 1. 17. Overgrowth of the Teeth of a Rabbit— Upper and lower jaws and forepart of the skull of an adult rabbit, with abnormal teeth. The animal when shot was eating a leaf with its back teeth, and was well nourished. The right lower incisor has been accidentally broken oflf after death. The left lower incisor projects forwards and curves Atrophy. 7 slightly upwards. Its upper and outer surface is worn by the inner surface of the upper incisor of the same side. The right upper incisor has curved round upon itself, and by pressure has caused absorption of the left upper jaw, which it has in this Avay penetrated. An additional ill-developed incisor lies behind it. The left upper incisor — though also overgrown — is shorter than its fellow, and has rubbed against the side of the left lower incisor. An additional incisor lies behind this tooth, and is shorter than the additional incisor of the right side. The first right lower molar has had no exactly opposing tooth, and has, in its overgrowth, penetrated into the upper jaw. A certain amount of overgrowth is also seen in the first and second right upper molars, and in the first left lower molar. G. C. 3115. Presented by A. Allen, L.R.C.S., 1889. ATEOPHY. PHYSIOLOGICAL — FROM OLD AGE. 1. 18. Atrophy of Mamma in Old Age.— Sections of mammary glands from two women, one adult, the other aged,— in spirit. The great contrast in size and thickness is at once apparent. G. C. 3101 and 3101a. Presented by Charles W. Cathcart, 1889. For Atrophy of Bone, see Series 6. FROM DIMINISHED FUNCTIOX. 1. 19. Atrophy of the Femur from Disease and Disuse.— Eight femur of a young man, macerated and dried, showing the above changes. The patient, for nine years before death, had been bedridden from spinal caries and psoas abscess. His age was said to have been 27 years, but his appearance after death was described as more like that of a General Pathology. lad of 18 or 19 ; and the condition of the epiphyses points to a similar conclusion. The bone is greatly attenuated in every way, and was unusually light. The compact tissue is, in many places, reduced to a mere shell. The articular surface of the head of the femur is partly absorbed and the bone opened out. G. C. 2145. Presented by Dr Gulland, 1840. 1. 20. Atrophy from Disuse.— Photograph of the atrophied stump of a femur, in contrast with the strong bone of the opposite side. From Professor Humphrey's paper. Journal of Anatomy and Physiology, April 1889. G. C.3535. Presented hy Charles "W. Cathcart, F.R.C.S.E., 1893. 1. 21. Atrophy of the Stump of a Femur after Amputa- tion.— Section of the end of the stump of a femur after amputation, macerated. The compact tissue is exceedingly light and thin, and has, in many parts, become cancellous. G. C. 3131. 1. 22. Muscle atrophied from Disuse. Specimen required. FEOM VARIOUS CAUSES. 1. 23. Muscle atrophied from Joint Disease. Specimen required. 1. 24. Muscle atrophied from Loss of Nerve Influence- Preparation — in spirit — of the forepart of the right foot of a lad, with atrophy of muscle. Atrophy. 9 The patient had suffered for many years from an obscure form of paralysis of the lower limbs, and the foot was amputated on account of a perforating ulcer of the heel. The muscles of the foot are all more or less atrophied. The extensor brevis digitorum, when fresh, was especially pale in colour. It is also diminished in bulk, and its tendons are reduced almost to threads. G. C. 3135. Presented by A. G. Miller, F.R.C.S.E., 1890. 1. 25. Atrophy of Optic Nepve following* Destruction of the Eyeball. — Preparation — in spirit — consisting of optic tracts, commissure, and nerves, with the eyeballs, one shrunken, show- ing changes in the nerve of the affected eyeball. The appearance of the shrunken eyeball indicates long- standing destruction, and the optic nerve on the same side is much smaller than its fellow. The sheath of the nerve, in each case, has been dissected off at a corresponding point. G. C. 3193. 1. 26. Atrophy from Excessive Use. Specimen required. 1. 27. Atrophy from diminished Blood Supply.— Heart degen- erated from calcification of coronary arteries. Specimen required. 1. 28. Degreneration from Starvation. Specimen required. 1. 29. Absorption of Vertebrae from Aneurismal Pressure. — Section of the bodies of three dorsal vertebrae, from a case of aneurism, — in spirit. 10 General Pathology. There is considerable hollowing out on the front of the vertebrae, and, as is usual in such cases, the bones have suffered more than the intervertebral discs, which stand out still com- paratively unchanged. The substance of the bones seems quite normal beyond the absorbed portion. G. C. 3103. 1. 30. Absorption of Vertebrae from Pressure in Lateral Curvature. — Lower four cervical and upper nine dorsal vertebree, from a case of lateral curvature — macerated. In the concavity of the arch formed by the seventh, eighth, and ninth vertebrae on the left side, the bodies have been compressed, and are in consequence much less in depth there than on the other side, where there is a convexity. This is due to the greater compression which always exists upon the concavity of an arch, as when a piece of wood is bent upon itself. G. C. 1637. Presented by F. Newbigging, F.R.C.S.E., 1835. 1. 31. From Invasion by Malignant Growth.— Part of the left half of the lower jaw of an old person, in which epithelioma of the lip had invaded the bone. Just behind the mental foramen the alveolar border of the bone has been invaded and its substance opened out and absorbed. G. C. 2888. Presented by Professor Annandale, 1889. INFLAMMATION. 1. 32. Increased Vascularity of an Inflamed Part.— Cast in gelatine and glycerine of a left hand, showing a condition of onychia — probably septic and tubercular — in a child aged 9 or 10 years. Several months before the cast was taken the nail had been bruised . in a gate, and the finger had remained inflamed. Infiammation. 11 Tlie redness and swelling round tlie end of the finger may be taken as illustrating an acute inflammation. It was, however, an acute exacerbation rather than a simple acute inflammation. The increased size of the nail indicates the previously congested condition of the parts, and may be taken as an instance of overgrowth from increased vascularity. G. C. 3125, P?-ese?i. cut out by the trephine " — macerated — " showing the necessity of inclining the instrument during the operation, owing to the variable thickness of the bones." E. C. 1. 2. M. 14. 3. 29. Irregularities in the Thickness of the Skull.— Skull-cap^ — macerated — showing fracture in the left temporal region, for which trephining had been performed. The irregularities in the thickness of the skull at the seat of operation and elsewhere are especially noteworthy. The saw, in removing the calvarium, has taken away more of the left than of the ri^ht side. E. C. 1. 2. M. 4. COMMINUTED FKACTUEES OF THE SKULL, WITH FISSURES LEADING FROM THEM. 3. 30. Depressed Fracture, with Fissures and Separation of Sutures. — Skull-cap, apparently of a young subject — macerated — showing the above. There has been a depressed fracture at the lower and anterior part of the left parietal bone, and the trephine has been applied, evidently to permit elevation of the fragments. Longitudinal fissures more extensive on the inside pass back- wards and forwards from the seat of injury. The coronal suture has been forced apart for about two inches on either side of the middle line, and. beyond that point on the right side, the line of separation has been continued as a fracture passing through the right parietal bone. F. P. C. 23. Presented ti/ Professor James Russell. Fractures of the Skull. 51 3. 31. Depressed Fracture of the Vault of the Skull, with a Fissure passing- into the Base.— Calvarium of a boy — macerated — showing a fracture of the frontal and right parietal bones. " This boy was brought into the hospital in a state of death-like insensibility, and his head misshapen. An effusion upon the temple tempted me to make an incision through the scalp, and there I found the bone shattered. I applied a small trephine, and afterwards the cranium saw, and took away the pieces of broken bone, and washed out the coagulum from under, but there followed no amelioration of symptoms. The boy died, and now it is seen that a fracture extended round the fore- head to the base of the skull, and that the injury was too great to allow of the expectation that the patient could live. " From the depression behind the seat of fracture, and from the horizontal fissure in the frontal bone, the injury must have been very severe. B. C. 1. 2. M. 2. 3. 32. Compound depressed Fracture of the Skull, with Fissure. — Calvarium of a boy — macerated — shovping com- minuted fracture of the right parietal "bone, with a fissure running backwards into the occipital bone. "The boy was kicked by a horse. The fragments were depressed,, and so tightly wedged down that the trephine had to be twice applied before they could be elevated. The dura mater was torn, and the brain lacerated by the injury. Some brain matter escaped. The patient remained insensible, had convulsions, and died in five days after the accident." B. C. 1. 2. M, 14 B. 3. 33. Laceration of Dura Mater from Fracture of the Skull. — Portion of dura mater — in spirit — from the previous case, showing a tear which lay below the seat of fracture. B. C. 1. 2. M. 16. 3. 34. Comminuted Fracture of the Vault of the Skull, with extensive Fissures leading* from it.— Skull— 52 Injuries of Bone. macerated — showing the above injury, with a trephine opening and the mark of a Hey's saw. The seat of injury has evidently been at the right parietal eminence, where comminution exists, and whence some com- minuted fragments have apparently been removed by trephin- ing. From the seat of injury at the right parietal bone one large fissure extends to the left beyond the middle of the left parietal bone. Another fissure passes forward into the coronal suture, and another descends through the back of the squamous portion of the temporal bone to end in the glenoid fossa. Another irregular fissure unites this with the coronal suture, and a small vertical split is seen in the mastoid process. The injury is one Avhich might have been produced by a heavy blow upon the right parietal bone. G. C. 1009. 3. 35. Severe Comminution and Fissuring* of the Skull.— Eight half of a skull — macerated — showing an extensive fracture. From a patient in Middlesex Hospital. The scalp was wounded over the right temple and the skull fissures radiate from this region. One fissure runs upwards from the temple along the coronal suture, and from the lower end of the split coronal suture an irregular fissure runs forward across the frontal bone to the orbit, and joins other fissures there. From the same starting-point a second fissure runs forwards and downwards to the roof of the orbit. A third, passing downwards, gives off a branch into the orbit, and then, continuing backwards, splits into two in front of the ear. One of these two runs in front of the meatus to reach the base, and the other, extending through the petrous and mastoid parts of the temporal bone, crosses the occipital bone . and ends in the foramen magnum. The bones have been so much loosened that it has been necessary to keep them together with wire. "Where the blow was received the fissure is very narrow, but on tracing it towards the base of the skull it is a gaping Fractures of the Skull. 53 rent. This is to be accounted for on the principle of counter fissure" (Sir Charles Bell). B. C. 1. 2. M. 6. 3. 36. Comminution of the Skull resulting" from a Fall. — Calvarium of a man — macerated — showing a very great comminution of the right side and fissures on the left. The patient was leaning out of a window in a court in the High Street. He lost his balance, and, after falling about thirty feet, landed on his head on the stone pavement below. He was brought at once to the Infirmary, but when admitted seemed to be dying. His head was flattened on the right side, and his right eye protruded from the orbit. There was no bleeding from ears, nose, or pharynx. A prominence in the back of the pharynx was taken to be a dislocation of the cervical vertebrte, and an unsuccessful attempt was made to reduce it. His pulse was slow and weak, and his breathing shallow and irregular. He died in about half an hour after the accident. The amount of comminution is indicated by the number of wires necessary to hold the fragments together, after the soft parts were removed. The following specimen is the other part of this skull. G. C. 3094. Presented by Macdonald Browk, F.R.C.S.E. 3. 37. Extensive Comminution of the Skull. — Base of the skull, with the three upper cervical vertebrae from the same patient as the previous specimen was taken from. The soft parts have been removed, except the dura mater and some ligaments. The anterior fissure seen passing forwards on the right side in the previous specimen can now be traced into the frontal bone, and thence downwards in the roof of the right orbit, to end in the mesial line near the foramen magnum. The roof of the right orbit and the outer wall of the right middle fossa are greatly comminuted. The right malar bone was broken, and a fissure (enlarged accidentally in cleaning the bone) involved the right half of the palate. On the left side there is a fissure beginning just above the external auditory meatus, and running irregularly 54 Injuries of Bone. upwards into the vault, while there is also a horizontal fissure in the frontal bone, starting from the fissure already noted there, and extending nearly to the fissure in the left temporal fossa. This specimen is important as showing that extensive comminu- tion of the vault and of the base, extending also into the bones of the face, may result from a fall upon the head. iS"© dislocation of the cervical vertebrae existed. A large hsematoma had produced the swelling in the pharynx. G. C. 3095. Presented by Macdonai.d Brown, F.R.C.S.E. 3. 38. Compound Fracture of the Vault of the Skull extending into the Base— Pyaemia — Death. — Calvarium — macerated — from a man aged 20, with separation of the left half of the coronal suture, and a small localised fracture just above the temporal ridge on the left side. On 27th July 1815 the patient was admitted to the Royallnfirmary, Edinburgh, witli the history of having fallen a height of 30 feet on to his liead. He had a scalp wound over the seat of fracture, and another above the left eye-brow. There was no bleeding from the nose or ears, and the patient was quite sensible. Pulse 66. He had slight vomiting at times, and his face had an anxious look. In the evening, as his pulse was 74, and as he complained of headache and restlessness, he was bled to 16 ounces, with little benefit. Next day four leeches were applied to each temple. On the third day the patient seemed wonderfully well, but some inflammation had begun round the temple wound. On the seventh day this wound was suppurating, and the bone below v,-as bare. Five leeches were applied to each temple. The Avound was poulticed, and antimony and saline mixture were given internally. From this time, in spite of repeated leeching and bleeding, he grew gradually worse, with headache, rapid pulse, and at first restlessness. Afterwards he became drowsy, and before death comatose. Rigors and vomiting •occurred on the seventeenth and eighteenth days. On the nineteenth day he was trepanned, and the diploe was found to be purulent. On the twentieth day after the accident he died. And on August 16th, at the post-mortem examination, about four ounces of blood was found lying over the left orbit. The dura mater below the seat of operation was sloughy externally, and internally was covered by purulent matter for some distance round. The fracture on the frontal bone was traced down to the base of the sknll. Fractures of the Skull. 55 Evidently this was , a case of pyaemia and septicaemia following a compound fracture of the skull. On the outside the bone is slightly roughened by inflamma- tion below and behind the trephine opening, and internally new bone has been thrown out in the main groove for the middle meningeal artery. G. C. 1010. 3. 39. Compound Fracture of the Skull— Consecutive Abscess — Death. — Calvarium of a boy — macerated — showing a hole in the right half of the frontal bone. Two portions of the bone which were removed from the hole immediately after the accident are wired in position near it. " The boy was kicked by a horse, and for four weeks was treated in the Royal Infirmary, Edinburgh. At the end of that time he left, apparently quite well, and with the wound healed. About five weeks after his dis- missal he was twice seized with fits, and was re-admitted into the Hospital. The wound was now tumid and painful. A small speck Of bone was removed from it. He lay in bed, listless and without complaining until he became suddenly blind ; he remained sensible, and could recognise his dresser's voice ; by his mother's account, his appetite was good. He died in strong convulsions. ^^ Dissection. — The scalp and dura mater adhered firmly together at the place of the cicatrix ; the edges of the bone and dura mater were separate. A very extensive abscess was found to occupy almost the whole of the right hemisphere of the brain. The thinnest parts of the walls of this abscess were opposite to the wound and at the base of the brain near the optic nerves. It was calculated that about eight ounces of pus wfere ■evacuated from the abscess. There was no dead bone found on dissection." The margins of the hole in the bone are rounded by the vital processes following the injury, whereas the margins of the loose fragments, removed at the time of the accident, are sharp. There are marks of increased vascularity all over the calvarium, especially on the inner side. B. C. 1. 2. M. 1-i c. 3.40. Septic Osteo-myelitis of the Skull, foUowingr Injury. — Calvarium — macerated — with a portion of dead bone in process of separation on the right side of the frontal bone. "This man lay with the surface of the cranium exposed, and 56 Injuries of Bone. the process of exfoliation going on. He was attacked with symptoms vvhiih were attributed for a time to the formation of matter under the skull, but which might be more correctly attributed to typhus fever, since after death no signs of affection of the brain could be discovered'* (Sir Charles Bell). The surface of the greater part of the frontal bone is roughened by the opening out of vascular pores, and the smooth dead portion of bone is surrounded by a groove formed by granulation tissue. There are two slight fissures in the frontal bone, one near the necrosed piece, and another at a corresponding place on the other side, but these may have been made in removing the calvarium. B. C. 1. 2. M. 14. D. 3.41. Compound Fracture of the Skull— Septic Osteo- myelitis— Death. — Portion of a cranium three weeks after fracture — macerated — with a dead piece in process of separa- tion. The dead piece is smooth and polished. The granulations have begun to cut a groove round it, and the adjacent bone is roughened by inflammation. The trephine has been applied. G. C. 1165. Presented by Professor James Russell. 3. 42. Compound Fracture of the Skull— Septic Osteo- myelitis— Death. — Portion of a cranium after fracture,, dura mater ^V^ situ — dried. Part of the bone is in process of separation. The trephine has been twice applied. The cause of death has probably been septicsemia or pyaemia. G. C. 1155. Presented by Professor James Russell. 3. 43. Compound Fracture of the Skull— Septic Osteo- myelitis— Death. — Portion of the right frontal and parietal bones — macerated — from a case of compound fracture. There has been extensive ulceration and necrosis, and Fractures of the Skull. 57 some bone is still in process of separation. The trephine has been thrice applied. G. C. 1156. Presented by Professor James Russell. 3. 44. Septic Osteo-myelitis of the Skull, following" Injury. — Part of the frontal bone of a " scrofulous boy " — macerated — showing a trephine opening and an irregular aperture from disease; In consequence of a blow the bone became inflamed and carious, and the trephine was applied "to evacuate the matter." On the outside the irregular, worm-eaten appearance resembles the effect of tuberculosis, but the new bone thrown out on the inside round the apertures more resembles the effect of septic irritation. G. C. 990. 3. 45. Septic Osteo-myelitis of the Skull, following Injury. — Portion of a right parietal bone, with the adjacent part of the occipital bone — macerated — showing the effect which followed an injury to the head. There has evidently been septic osteo-myelitis, followed by necrosis. Most of the dead bone has been separated, but a small piece in process of separation still remains. The results of inflammation are much more numerous on the outer than on the inner aspect of the bone. The patient has been trephined as in the cases from which several of the previous specimens were taken. G. C. 595. 3. 46. Healed Fracture of the Skull.— Vault and part of the base of a skull, with an extensive old-standing fracture which had healed. The marks of a fissure healed by bone are seen in the left half of the frontal bone and in the right parietal bone. In the line of the fissure, at the right side of the coronal suture, there 58 Injuries of Bone. is a longitudinal gap in the bone measuring 2| by 1| inches. Its edges are smoothed and bevelled down to the level of the dura mater. On the inner aspect there are irregular markings, from chronic inflammation. Probably there has been a compound comminuted fracture at the coronal suture, with a fissure extending obliquely forwards and backwards from this, and followed by necrosis of the comminuted fragments. The specimen was found in Bamburgh Churchyard, Northumberland, in 1832. G. C. 1437. Presented hy John Embleton, Esq. 3. 47. Old-standing- Fracture of the Skull, with loss of Substance. — Part of a skull, with considerable loss of sub- stance, said to be the result of fracture — in spirit. The gap is filled by the dura mater. The bevelled and smoothed edges of the bony margin show that 'healing had taken place, but the sloughy look at one spot and the appear- ance of lymph on the inside indicate that inflammation had broken out afresh. G. C. 1058. Presented by Professor James Russell. GUNSHOT FEACTUEES OF THE SKULL. 3. 48. Bullet Wound of the Skull, from the Battlefield of Culloden. — Calvarium of an adult — macerated — which has been perforated by a musket ball from front to back. "The skull was found on that part of the field of Culloden where the Highlanders, wrapping their plaids about their left arms, and stooping low, made their attack on the King's troops." In the upper part of the frontal bone, to the left of the middle line, there is an oval aperture measuring \\ inch by 1 inch. Its margin is regular on the outer surface, but on the Gunshot fractures of the Skull. 59 cranial surface the bone is chipped off irregularly round. At the back, in the right side of the occipital bone, between the superior curved line and the lanibdoidal sviture, there is a larger and more irregular aperture measuring IJ- by 1^ inch. In this case the greater irregularity and chipping off is seen on the outer surface, while the cranial margin is smooth, a condition the reverse of what is present at the anterior aperture. As it is known that with the musket ball, at least, the entrance wound in the skull was smaller than the exit wound, and that the bevelling is with any bullet always on the margins of the apertures towards which the bullet is travelling, the condition of the apertures in this skull entirely corroborate the historical account of the action on that part of the battle- field on which it was found. B. C. xvii. 3. 3. 49. Bullet Wound of the Skull. — Portion of the right parietal bone behind and above the ear — macerated — to show aperture produced by a bullet wound. The man, who was a servant, had shot himself. He lived for forty- eight hours afterwards. The bullet split in two. One part was found beneath the scalp, three inches from the wound, and the other part passed inwards, and was found beside the falciform process of the dura mater. The hole is larger in its vertical than in its transverse measurement, probably from the upward direction of the shot, and the chipping is greater upon the cranial than upon the outer margin of the aperture. It may be noted that the bevelling is greater on the inner and upper surfaces, than upon the posterior and lower surfaces, probably indicating the direction of the bullet. At the upper j^art of the outer margin some lead has been impacted. This probably points to where the ball was split. B. C. XVII. 2. 3. 50. Gunshot Wound of the Skull, from a Pistol held close to the Temple. — Front half of the vault of 60 Injuries of Bone. the skull of a man who lived for six days after having sliot himself with a pistol in the right temple. Sir Charles Bell saw the patient the day after the injury, and found him "more rational than he had been for some weeks." His face was enormously swollen and distorted. An incision was made over the left temple. After raising the bone, the ball was found flattened and was extracted. The patient survived for four days after this. There is an aperture, 3| inches by \ inch, at the anterior inferior angle of the right parietal bone. The chipping off within shows that the ball had entered there. On the left side,, above the outer end of the left supraciliary ridge, the bone is extensively broken and splintered, and more so externally than internally, indicating that the shot had struck that part from within. B. C. 1. 2. M. 12. 3. 51. Bullet Wound of the Skull. — Four pieces of a soldier's skull and a round bullet — Waterloo case. "Here the ball entered the brain, and, making its exit, drove up portions of the skull, which were driven up by the ball which lay within the brain {sic). In extracting the ball a portion of the brain came out. The patient did well, complaining from the first only of headache. " B. C. XVII. 4. 3. 51a. Bullet Wound of the Skull.— Oil painting by Sir Charles Bell, showing the above. " The ball entered in the forehead, penetrated the skull and drove- up the bone, elevating two portions at an angle. The scalp was cut upon at this part, the bone raised and the ball extracted. ... I .... do not know his fate." B. C. XVll. 10. 3. 52. Bullet Wound of the Skull.— Portions of a soldier's skull, fractured by a bullet wound. The patient was struck with a musket ball, which caused a circular depression formed by these fragments, and they were removed mthout the aid of a trephine. "The man had no bad symptoms, and did well."' (Probably a spent shot.) ^ Q x\u 7a Gunshot fractures of the Skull. 61 3. 53. Bullet Wound of the Skull.— Oil painting by Sir Charles Bell, showing the wound from which the specimens forming the previous preparation were taken. The aperture is circular, but it is expressly stated that the trephine was not used. B. C. xvii. 9. 3. 53a. Gunshot Injury of the Scalp.— Oil painting by Sir Charles Bell, showing the above. " Sketch of a soldier who received a musket ball in the forehead which had run under the scalp, and was cut out and found to be flattened. B. C. XVII. 8. 3. 54. Cannon-ball Wound of the Skull. — Portion of the occipital bone, with the soft parts cleaned oif, except at the aperture in the bone — in spirit. The injury is said to have been produced by a cannon-ball. The patient had evidently survived for months at least. The gap has been filled by fibrous tissue, one fissure has healed by bone, and marks of chronic inflammation remain on the interior of the bone surrounding the deficiency. G. C. 1072. Presented by Professor James Russell. 3. 55. Cannon-ball Wound of the Skull.— Portion of a skull- macerated — showing a small aperture, with new bone for- mation in the neighbourhood. The patient was injured by a cannon-ball. He did well for a time, but afterwards died. The specimen shows a small aperture with rounded margins (more like a bullet wound). The surrounding bone shows signs of considerable inflammation, and much new bone is thrown out especially on the cranial aspect. G. C. 1151. Presented by Professor James Russell. 3. 56. Fracture of the Cranium by a Musket Shot.— 62 Injuries of Bone. Skull of a young adult — macerated — to show a bullet wound and trephine opening in the left frontal region. ' ' The ball struck this soldier on the sphenoidal angle of the frontal bone. It fractured the bone into small pieces. These were picked away, and a question arose whether or not the ball had entered. The dura mater was entire. It had not, then, entered the cavity, and an examina- tion being made with the probe under the skull, the ball was discovered lodged above the left eye. Calculation being made of its exact distance from the place of the fracture, the trephine was applied there, and the ball extracted. The portion of the bone cut out by the trephine is attached to the skull, and the ball is replaced. The ball is flattened in that manner to give the idea of its only being half a ball. The man died of suppuration in the brain." The piece of bone and the ball alluded to in Sir Charles Bell's account of the case have been mislaid or lost. The upper left canine tooth is retained within the alveolus in this skull. B. C. xvii. 1. 3. 57. Old standing- Pistol Shot Fracture of the Skull.— Skull of an aboriginal Australian from Upper Brisbane, Queensland, Moreton district — macerated — showing an old- standing injury in the right frontal region. " While uncivilised, this man was shot in the head by a squatter at 60 yards distance (size of bullet, No. 12). The ball penetrated just above the right supraciliary ridge, and destroyed part of the roof of the orbit, where it seems to have been lodged. For two weeks the man suffered from paroxysms of intense pain. The bullet was then spontan- eously discharged, along with much pus, and he soon recovered. For the next seven years until his death he acted as a shepherd, and was very intelligent for a native. During three years he suffered from a dull headache more or less constant. He was killed in a quarrel with another native." The skull is very heavy and thick, and the bony ridges are strongly marked. G. C. 2531. Presented by Forbes, Esq. 3. 58. Sabre Wounds of the Skull.— Skull of a young adult, showing sabre cuts behind the vertex. It was picked up on the field of the battle of the Pyramids. There are three parallel cuts in the back of the skull, and Frachires of the Lower Jaw. 63 a large piece of bone has been taken out between two of them, B. C. xvii. 6, 3. 59. Sabre Wounds of the Skull.— Skull cap of an adult- macerated — showing the above. The soldier had been one of Napoleon Buonaparte's cuirassiers at the Battle of "Waterloo. There are eleven sabre cuts, all about the vertex of the skull. Figured in Dr Hennen's "Principles of Military Surgery," 1st edition, p. 283, plate vi. fig. 5. Presented by Professor John Thomson. 3. 60. Sabre Fracture of the Skull.— Portion of the skull of a French soldier — macerated. It was detached by a sabre cut, and removed by Sir Charles Bell. The man had received numerous sabre wounds. Waterloo case. B. C. XVII. 5. FEACTUKES OF THE LOWER JAW. 3.61. Double fracture of the Lower Jaw.— Lower jaw of an adult — macerated — showing fracture in two places. The patient, aged 67, fell from his cart. The second, third, and fourth ribs of his right side and the second rib of his left side were broken. The portion of the lower jaw between the fractures was stripped of its periosteum, and as it lay loose in the mouth it was removed. A wound extended from the (left) angle of the mouth downwards. The nasal bones were fractured. The patient died in three days after the injury. On the right side the fracture is vertical, and lies in front of the canine tooth. On the left side it is oblique, and, begin- ning behind the canine, runs downwards and backwards. G. C. 1299. Presented by Dr John Campbell. 3. 62. Fracture of the Lower Jaw.— Greater part of the lower jaw of a young man broken off during life — macerated. 64 Injuries of Bone. He was ploughing in Australia, and fell before the plough, which dragged out this piece of bone. He recovered. Presented to Dr Struthers by his pupil, Mr John Thomson, 1862-63. G. C. 3470. Presented hy Trofessor Struthers, F.R.C.S.E., 1893. 3. 63. Ununited Fracture of the Lower Jaw.— Right and left portions of the lower jaw of an adult — macerated — showing the above. The ends of both pieces are atrophied, especially, however, the right. This one is also smaller, and shows - less prominent ridges for the attachment of the masseter, and has a smaller and relatively shorter condyle. B. C. i. 1. M. 12. FRACTUEES OF THE SPINE. 3. 64. Fracture of the Atlas and Axis.— Atlas and axis- macerated — showing the above. The man from whom this specimen was taken had fallen from a height of 50 feet, and, landing upon his shoulders, was instantly killed. The dorsal part of his spine was also extensively injured. (See 3. 77.) The anterior arch of the atlas and the odontoid process of the axis at its junction with the body are broken through, and a portion of the former is broken off. B. C. 1. 4. M. 1, 3. 65. Fracture of the Posterior Arch of the Atlas and Odontoid Process of the Axis. — Wax cast of a fractured atlas and axis in which there had been great displacement with- out any pressure upon the spinal cord. The patient from whom the specimen was taken was a powerful though scrofulous man aged 32. Nine months before his death he had fallen from a hay-rick, and landed on his occiput. He was stunned by the fall, but was soon able to walk half a mile to see his doctor. In two days he was attending to his ordinary work as an agricultural labourer, with only stiffness of his neck. Symptoms of inflammation set iu at tJie seat of Fractures of the Spine. 65 fracture for which leeches and setons were applied, without much benefit. Afterwards he had a sharp attack of pleurisy, followed by severe hydro- thorax and general cedema, from which he died. From first to last there was no evidence of aifection of either motion or sensation. (See Medico- Chirurgical Transactions, London, vol. xx. p. 78.) The remarkable escape of the spinal cord is explained by the fact that the posterior part of the arch of the atlas remained in position while the rest of the bone was dislocated forwards, carrying with it the odontoid process, which was at the same time snapped off. This accident seems to be unique. G. C. 2782. 3. 66. Fracture of the Fourth Cervical Vertebra.— Axis and five succeeding cervical vertebrae, with the spinal canal laid open ; muscles dissected off — in spirit. The right vertebral artery was torn, and severe bleeding took place into the spinal canal and compressed the cord. The nerves and membranes were found perfectly natural and undisturbed. There is an oblique fracture through the upper jjart of the body of the fourth cervical vertebra, which extends into the left transverse process. The articular processes between the third and fourth vertebrae have been dislocated on the left side. G. C. 909. Presented by William Newbigging, F.R.C.S.E., 1827. 3. 67. Dislocation between the fourth and fifth Cervical Vertebrae. — Cervical and first dorsal vertebrae, with the muscles dissected off — in spirit. A fishwife, apparently in good health, was being pulled out of bed, in a frolic, by companions. It is uncertain whether the accident occurred when the head alone rested on the edge of the bed, or when it reached the floor. The limbs and trunk were paralysed. Breathing was carried on by the diaphragm for a day or two, until death took place. There is no appearance of fracture, and the dura mater appears to be drawn out between the separated vertebrae. G. G. 3456. Presented by Professor John Steuthers, 1893. E 66 Injuries of Bone. 3. 68. Dislocation and Fracture between the fourth and fifth Cervical Vertebrae — Upper five cervical vertebrae, spines and laminse removed, the dura mater opened, and a longitudinal section made of the spinal cord. The muscles are partly cleaned away, and the preparation is in spirit. The spinal cord has been crushed opposite the interval between the bodies of the fourth and fifth cervical vertebrae. The fifth vertebra is attached to the fourth only by the- nerves of the spinal cord. G. C. 2056. Presented hy Alexander Watson, F.R.C.S. E. 3. 69. Complete Dislocation forwards of the Body of the fourth Cervical Vertebra, with partial Fracture of its Laminae. — Section to the left of the middle line of the upper six cervical vertebrae, showing the above — in spirit. The spinal cord has been crushed between the laminae of the fourth and the body of the fifth vertebrae. Xote the com- paratively small irregularity of the spinous processes, which is compatible with such a serious pressure upon the cord by the dislocation of the bodies. G. C. 2095. Presented hy Alexander Watson, F.R.C.S.E., 1839. 3. 70. Fracture and Dislocation of the fifth and sixth Cervical Vertebrae, with Fracture of the fourth and fifth Spines. — Lower six cervical vertebrae, with the muscles cleaned off — in spirit, showing the above injury. " J. S., ret. 45, fell backwards from a height of four feet, and landed on the back of his neck against an iron railing. "The house surgeon reports of this man that -when he was brought into the Hospital he was perfectly sensible ; that his face indicated great alarm and anxiety. Every time he drew his breath it was attended with an effort to raise his shoulders, and a contraction of the muscles of the throat. Every time he breathed liis head appeared to sink beneath his shoulders. On putting the hand on the pit of his Fractures of the Spine. 67 stomach no motion of the viscera of the abdomen could be perceived. He had no feeling even in the upper part of his chest ; he had feeling on his face and neck, and indistinctly near the collar-bone. He had a motion of his hands, a sort of rolling motion, which may have proceeded from the shoulders. When he spoke it was in a tremulous voice, like a man frightened. His voice was weak, but he did not speak in a whisper ; the sound of his voice was more like sighing than common breathing. Pulse was felt at his wrist. In ten minutes after he was brought in, half an hour from the time of the accident, he died." The spinous processes of the fourth and fifth cervical vertebrae are broken off at their roots, the bodies of the fifth and sixth cervical vertebrae have been dislocated, and the upper part of the sixth vertebra has been fractured. The fifth transverse process has been broken on the right side, and the sixth and seventh on the left side. "It is clearly proved both by the sj'mptoms and the dissection of the bones, that the fracture must have affected the roots of the phrenic nerves ; and we are at liberty to conclude that the difiference of symptoms, in comparing it with the first case (3. 71) as well as the shorter period of his sufferings, was due to this cause." (Sir Charles Bell's " Exposi- tion of Nervous System," p. 237.) B. C. 1. 4. M. 3. 3, 71. Fracture of the Bodies and Arches of the fifth and sixth Cervical Vertebrae. — Lower six cervical and first dorsal vertebrae, with the muscles cleaned off to show the above injury — in spirit. "Charles 0., £et. 36, fell through a window into an area thirteen feet below. He thought that he landed on his back, but was uncertain, as he lay for some time insensible. In Hospital he lay supine — legs powerless and insensible, abdominal muscles relaxed and powerless, and viscera flaccid. His water had to be drawn off with a catheter, and his faeces were passed involuntarily ; priapism was present. Skin of abdomen and up to the nipples insensible. However, he had feeling in his stomach when it was pressed upon, and complained of the griping of some of his medicines. " His breathing was frequent. At each inspiration the chest was heaved with a short, quick movement ; at each expiration the belly was protruded by a sudden shock and undulation {sic). The belly during this 68 Injuries of Bone. effort of breathing, was uniformly soft and full, drawn in by the elevation of the ribs, and protruded when they fell again. " He could yawn, but could not cough nor otherwise strongly expire except by the weight of his thorax. ' ' During inspiration the serratus magnus and lower part of the trapezius could be felt in action. "He could raise his shoulders, rotate his humerus, and flex his fore-arms, but had no power over his hands. The skin of his ' arms ' was sensitive to the prick of a pin. ' ' He died on the night of the seventh day from the accident. " (Case of Charles Osborne in Bell's " Exposition of the Nervous System," p. 225.) The bodies of the fifth and sixth cervical vertebrae have been crushed. The lamina of the fourth vertebra has been broken, and those of the fifth and sixth have been comminuted on the left side. The movements of the arms described indicate the escape of the fifth cervical nerves from injury. B. C. 1. 4. M. 4. 3. 72. Dislocation of the fifth and sixth Cervical Vertebrae. — Lower six cervical vertebrae, with the muscles cleaned off — in spirit, showing the above (without apparent fracture). The ligaments are torn through between the laminae and spinous processes, but at the body some have been left. B. C. 1. 4. M. 5. 3. 73. Dislocation of the fifth and sixth Cervical Verte- brae, followed by Suppuration within the Canal. — Lower six cervical vertebra^, with the muscles cleaned off — in spirit — showing the above dislocation. ' ' Marshall, a coal waggoner, was riding on the shaft of his cart, when by a sudden jerk he was thrown off, and pitched on the back of his neck and shoulders. There was a swelling and discolouration between his shoulders. Although he could not stand, yet he could drag his legs after him, when he was supported to his bed. For nearly a week he lay complaining of nothing, and had no symptoms of paralysis. He could throw his arms and legs about, and retain his faeces and urine, and expel them naturally. On the eighth day, he was suddenly seized with con- vulsions over the whole body. After having been bled, he remained Fractures of the Spine. 69 sensible, thougli his jaw was locked. His convulsions returned, and he was relieved by bleeding. In a few hours his jaw began to move with great rapidity, and continued moving in an extraordinary manner for nearly ilve minutes, when all at once he exclaimed that he could speak. He was maniacal. He proved he was not at all paralytic, for it required two men to hold him, and he almost sprung out of bed to be revenged on the nurse. He passed a great deal of fseces and flatus with singular force. In twelve hours he became again rational. On the third day after the attack of convulsions he complained of difficulty in using his arm, and two days after he had total palsy of the lower extremities, which was more remarkable as at this time he regained the use of his arm. He lived for a week after this, but continued sinking, and still retained about him much of the character of typhus fever. The day before his death he was perfectly sensible, and had recovered sensation in his legs, for he could feel the rubbing of a finger upon them. At this time, although he appeared to pass his faeces involuntarily, still he passed them with great force, and he was able to eject an enema which was given contrary to his desire. Dissection. — The brain was examined carefully, and nothing was remarked except a little effusion between the pia mater and tunica arachnoides. On cutting the muscles by the side of the last cervical vertebra, a little pus oozed out. It was found to come from between the vertebne. On dissecting up the muscles, there was found to be an evident loosening of the last cervical from the first dorsal vertebrae. The inter- ventral substance was completely destroyed, and an immense quantity of pus surrounded them. On the back part the pus had extended under the scapula, and on the fore part was bounded by the oesophagus. On examining the spinal canal, the pus was found to have dropped down the whole length of the sheath to the cauda-equina." ((Sec Bell's "Surgical Observations," 1816, p. 145.) There is a complete dislocation, without apparent fracture. The anterior ligament is stripped off the seventh cervical vertebra, but without being torn through ; the other ligaments have been ruptured. B. C. 1. 4. M. 6. 3.74. Partial Dislocation forwards and Fracture of the sixth Cervical Vertebra. — Last three cervical and first dorsal vertebrae — partially macerated, dried and varnished, showing the above condition of the sixth vertebra. Paralysis of the body below. He lived twenty hours. (Case of William Wood, Royal Infirmary, Edinburgh, 1804.) On the left side the lower articular process of the sixth 70 Injuries of Bone. cervical vertebra has been dislocated forwards ; on the right side the lower articular process with adjacent part of lamina has been broken from the rest of the bone. There has been a slight fracture of the upper part of the body of the seventh cervical vertebra, especially towards the left side. G. C. 173a. Presented hy William Brown, F.R.C.S.E. 3. 75. Dislocation between the last Cervical and first Dorsal Vertebrae. — Last three cervical and upper three dorsal vertebrae, with the muscles cleaned off — in spirit — showing the above dislocation. ' ' The man fell headlong from a barge lying aground in the Thames. His head stuck in the mud, and the whole weight of his trunk and limbs was thrown on the neck, and an obliquity in the direction of the force probably twisted the vertebrte. He died instantly." There seems to be no indication of fracture. The dura mater is seen between the separated vertebrae. B.C. 1. 4. M. 7. 3. 76. Severe Crushing* Fracture of the third and fourth Dorsal Vertebrae. — First seven dorsal vertebrae, with the adjacent parts of the ribs — cleaned, dried, and varnished, and the canal exposed by the removal of the laminae on the right side, showing the above condition. The patient was a lad, aged seventeen. There was paralysis below the injury, with priapism. He lived twenty-five days. The adjacent parts of the third and fourth bodies have been greatly crushed. The remainder of the body of the third, with those of the vertebrae above, have been displaced forwards. The heads of the fourth ribs on both sides, as well as those of the lifth, sixth, and seventh ribs on the right side have been broken. The spine of the first, and the spines and laminae of the second and third vertebrae, have also been fractured. The cord must have been crushed. This has evidently been a case of fracture by forcing the spine forwards. Presented bu \fM. Browx, F.R.C.S.E., 1807. Fractures of the Spine. 71 3. 77. Crushing: of the Body of the fifth Dorsal Vertebrae with Fracture of several Spines and Ribs.— Lower five cervical and upper seven dorsal vertebrae, vpith the adjacent portions of ribs — macerated and dried, showing the above injury. The patient, a man, having fallen from a height of 50 feet, landed on his shoulders, and was instantly killed by compression of the cord just below the medulla oblongata {see 3. 64). The Avhole of the body of the fifth and the upper part of that of the sixth dorsal vertebree have been comminuted by crushing. There is also fracture of the seventh cervical and first four dorsal spines, and fracture of the first, second, third, fourth, and sixth right ribs, and of the fifth and sixth left ribs at their articulations with the bodies and the transverse processes of the vertebrae. The crushing of the fifth body has probably been caused by the forcible forward bending of the spine, while the injury to the spinous processes and ribs may have been the result of direct violence. B. C. 1. 4. M. 15. 3. 78. Severe Crushing* and Comminution of the Body of the sixth and Part of that of the seventh Dorsal Vertebrae. — Lower part of the third and following six dorsal vertebrae, with the adjacent parts of the ribs. The muscles and most of the ligaments are cleaned off — in spirit — showing the above injury. "Thomas AVills, ret. 30, while trying to extinguish a fire, fell from the roof of a house for a distance of two stories, and landed with his back upon the pavement. (He seems to have been doubled forwards, and perhaps turned a somersault as he struck the ground. ) "No injury to the spine was to be felt, but he had lost sensation of and motion in all the lower part of his body and lower extremities. The bladder and intestines were insensible to their natural stimuli ; he complained of a pain in his back, and referred it to the middle dorsal vertebrse, "Respiration was performed by a heaving of his chest, the abdomen being full and flaccid. There was a catch in his breath from pain running round his ribs on a line with the injury of the spine. "For six days he remained in this state, the catheter being used twice dailv. 72 Injuries of Bone. " At the end of this time his breathing became more affected. On the twelfth day after the injury his breathing became more rapid — 60 per minute. It afterwards became slower, and he died. He was frequently bled and cupped, but without relief. " At the post-mortem examination much coagulated blood lay over the sixth and seventh dorsal vertebra, and the spinous processes of these vertebraj were broken. The tube of the spine was forced in upon the spinal marrow, and a sharp portion of bone belonging to the body of the vertebra had pierced and lay pressing on the spinal marrow. A rib was fractured on the left side, the broken extremity of which pressed against the pleura. This side of the chest showed marks of inflammation." The body of the sixth dorsal vertebra is severely crushed and comminuted, as in the previous specimen, and the upper- part of the seventh body has been broken off on the right side. The heads of the fifth and sixth ribs have been broken off on the left side. The laminae and spine of the sixth vertebra has been fractured horizontally, and the left lamina of the' seventh vertebra vertically. One of the pieces of the body of the sixth vertebra was driven back upon the spinal cord. B. C. 1. 4. M. 8. 3. 79. Healed Fracture of the Dorsal Spine, after Severe Crushing". — Dorsal vertebrae, from the sixth to the eleventh in- clusive, with the corresponding ribs — macerated and dried. The laminae are removed to expose the spinal canal from the back. The spinal cord was torn across, and the patient survived the injury nearly two months. The condition seen is the result of extensive crushing and comminution of the bodies of the seventh, eighth, and ninth vertebra;, with subsequent healing. The spinal canal is entirely obliterated by crushing back of the bodies upon it. The crushing has been so complete that^ except for the presence of the ribs, it would have been almost impossible to have said how many vertebrae were involved. On the left side, the seventh, eighth, and ninth ribs are packed as closely as they will go. It may be noted that, as is com- Fractures of the Spine. 73 monly the case, the upper part of the spinal column is displaced in front of the lower. G. C. 1473. Presented through Sir George Ballingall by Drs Bkiggs, Mudie, and Thomson of St Andrews, 1833. 3. 80. Fracture of the Spine in the Mid-Dorsal Region.— Fifth to ninth dorsal vertebrae — macerated and dried — showing the above injury. The seventh vertebra has suffered most of all. Its body is comminuted, its transverse processes broken off, and its laminae fractured near the pedicles. The front of the eighth body has been broken off; also the following transverse processes, the right of the fifth vertebra, both of the sixth, and the left of the eighth and ninth. The fracture has evidently been pro- duced by bending forward the spine, with the usual tendency to forward displacement of the upper fractured portion of the column. G. C. 3309. 3. 8 1 . Displacement forward of the ninth Dorsal Vertebra and partial Fracture of the tenth, with Crushing- of the Cord. — Section of the lower half of the ninth and of the tenth, eleventh, and twelfth dorsal vertebrae. The muscles are dissected off, and the preparation is mounted in spirit, to show the above injury. The patient, a miner, set. 29, was doubled forwards by a mass of earth falling upon his shoulders. He had complete loss of motion and sensation in his lower limbs. He could not make water, but the bladder emptied itself after a catheter had been inserted. A plaster jacket was applied. On the third day he had septic cystitis, very fcetid urine, and considerable pain across the abdomen. On the ninth day he died of collapse, with vomiting, belching, and abdominal symptoms. At the post-mortem examination the bladder was found to have sloughed into the peritoneum, and his death had been due to septic peritonitis. The body of the ninth dorsal vertebra has been crushed 74 Injuries of Bone. downwards and forwards, and the spinal cord and accom panying nerves have been crushed between the body of the tenth and the lamina of the ninth vertebrae. G. C. 2903. Presented by John Duncan, F.R.C.S.E. 3. 82. Fracture throug-h the tenth Dorsal Vertebra in an Old Man. — Portion of the ninth and the tenth, eleventh, and twelfth dorsal and first lumbar vertebrae — the muscles cleaned off, dried and partly varnished, to show the above condition. The spine had previously been anchylosed, and therefore would not bend. The fracture has passed irregularly through the body, lamina, and spinous processes. The bony masses which had produced the previous anchylosis are seen on either side of the front of the bodies {Arthritis deformans). See Bell's "Observ. on Injury of the Spine and Thigh Bone," plate ii. fig. 1. B. C. 1. 4. M. 14. 3. 83. Dislocation forwards of the tenth, and Fracture of the Body of the eleventh Dorsal Vertebrae.— Section through the bodies and laminae of the lower part of the sixth and of the seventh, eighth, ninth, and tenth, and part of the eleventh dorsal vertebrae, to show the canal from the front. The muscles are dissected off — in spirit. The body of the tenth vertebra has been displaced for- wards and downwards, and has crushed a fragment from the upper and back part of the eleventh vertebra back iipon the spinal cord, so as to bruise and compress it. An irregular fracture is seen running through the body of the eleventh vertebra. This specimen was used by Sir Charles Bell as an argument for the uselessness of trephining the spine after injury. Figured in Bell's " Observ. on Injury of the Spine and Thigh Bone," plate i. fig. 1. B. C. 1. 4. M. 11. Fractures of the Spine. 75 3. 84. Forward Dislocation and Fracture of the Body of the eleventh, and Fracture of that of the twelfth Dorsal Vertebrae. — Eleventh and twelfth dorsal and first lumbar vertebrae — cleaned, dried, and varnished, to show the above condition. The patient, John Cameron, was admitted to the Royal Infirmary, Edinburgh, on 12th October 1807, with loss of motion and sensation below the thorax, as the result of an injury. About a week before death it was noted that his water continued to be mixed with purulent matter, and also that the catheter was introduced with diflBculty, apparently from its point getting into a false passage. There was a very extensive slough over the os sacrum, as well as over the injured part of the spine, the latter being on the increase. At this time the patient was incoherent, and took little food. On the morning of 2nd November he was attacked with spontaneous vomiting of a greenish-coloured matter, and on the following day his pulse could hardly be felt at the wrist, while the vomiting had been continuous. On 4th November — i.e., twenty-three days after the accident — he died. The spinal canal must have been completely obliterated and the lower end of the cord crushed. G. C. 173 B. Presented hi]\N-su Bkowx, F.R.C.S.E., 1807. 3. 85. Dislocation forwards of the eleventh, with Fracture of the Body of the twelfth Vertebra.— Sections of the last three dorsal and first lumbar vertebrae, with the muscles cleaned off, showing compression of the cord by displacement of the vertebrae — in spirit. A. M., set. 31, a fireman, on 26th February 1891 fell through a hatchway into the forepeak, a distance of ten feet, and must have landed across an iron M'heel, but cannot say how he struck it, as he was rendered unconscious. He was pulled up by the sailors, by means of a rope under his arm-pits, carried to his berth, and next day taken to Hamburg Hospital. There he lay for two months till he was brought to Leith, and admitted to the Royal Infirmary, Edinburgh, on 29th April 1891. On admission he was very white, weak, and prostrate. He had no feeling below the iliac crests, and neither movement nor sensation in the lower limbs. There was tactile sensation in the lumbar region, but it was delayed. Some hypersesthesia existed above the twelfth rib. There was a depression below the twelfth dorsal spine. There were bedsores on the sacrum, the calves, and at the malleoli of both legs. Sphincters were relaxed, and fteces and the urine came away involuntarily. The urine 76 Injuries of Bone. was turbid and ammoniacal. The patient's bladder was washed out, and his bedsores attended to. In spite of all treatment, he got gradually weaker, and died, partly of exhaustion, and partly of septic absorption, about two months after his admission. The portion suspended above shows well the compression and crushing of tlie anterior part of the body of the twelfth, with the forward displacement of the eleventh dorsal vertebra, so as to diminish the spinal canal by drawing the laminse of the eleventh towards tlie upper part of the body of the twelfth. The portion of the specimen suspended below shows the effect of this displacement upon the lower end of the cord, and the nerves accompanying it. G. C. 3316. Presented by A. G. Miller, F.R.C.S.E. 3. 86. Dislocation forwards of the eleventh, with Fracture and crushing" backwards of the Body of the twelfth Dorsal Vertebra. — Last two dorsal and upper two lumbar vertebrae — cleaned and dried — showing the above injury. The right halves of the bodies have been removed, so as to dis- play the canal from the front. The patient lived for about six weeks after the accident. The crushing backwards of the last dorsal body has been so great that at their anterior margins, the lower border of the eleventh dorsal and tlie upper border of the first lumbar verte- brae almost touch, and the body of the twelfth dorsal vertebra has been crushed back upon the canal, so as to com- pletely obliterate it. F. P. C. 51. 3. 87. Dislocation forwards of the last Dorsal, with Fracture and Displacement of the first Lumbar VertebrSB. — Section of the bodies and laminse of the last two dorsal and first four lumbar vertebrae — with the muscles cleaned off" — in spirit, showing the above condition. The i)atient was a coal miner, and while working in a pit was struck on the back by a mass of earth. Fractures of the Spine. 77 At first he was said to have had some movement in his legs, but by the time he reached the Royal Infirmary, Edinburgh, all motion and sen- sation in his lower extremities had disappeared. His bladder was paralysed, and in two days hfematuria began and continued. In spite of every care in cleansing the catheter used to draw off his water, septic cystitis appeared in a few days, and carried him off about a week after the accident. At the post-mortem examination the mucous membrane of the bladder was found greatly congested, and at places sloughing. The con- gestion extended up both ureters. The left kidney was bruised. The end of the spinal cord and beginning of the cauda equina have been crushed between the laminee of the twelfth dorsal and the body of the first lumbar vertebrae. The anterior part of the first lumbar vertebra has been so much crushed that the anterior margins of the last dorsal and second lumbar vertebrae nearly meet. G. C. 2799. Presented by John Duncan, F.R.C.S.E. 3. 88. Fracture of the Spinal Column at the Level of the second Lumbar Vertebra. — Lower part of the last dorsal and first three lumbar vertebrae — muscles cleaned ofi" — in spirit, showing the above injury. "A young man, named Auton, 25 years of age, a plasterer, fell from a height of 40 feet, and in his descent his back struck against the corner of a stone stair, about 18 feet from the ground. When brought to the Hospital, a swelling was to be felt over the lower dorsal vertebrte. On pressing the finger deep, a depression or interval betwixt the spinous processes could be distinguished. He complained of great pain in the part, and all over the abdomen. He breathed naturally, and was perfectly sensible ; there was no defect of motion or of feeling in the lower extremities. He was bled to sixteen ounces, twelve leeches were apjilied to his back, and he had a dose of the house physic. He was admitted September 12th, 1816. " ISth. — He has passed a restless night. He is in great pain ; he vomits everything he takes ; the purgative mixture was rejected, and he had no relief in his bowels. An enema ordered. " lith.—B-e is delirious. His pulse frequent, not full ; his skin hot. He passes his faeces and urine involuntarily, but there is no flaccidity of the abdominal muscles, and he has the perfect use of his limbs. " 15th. — This young man's condition is very threatening ; his pulse is 136. He was delirious during the night, and threw himself out of bed. He is now in a state of extraordinary excitement, and although he has 78 Injuries of Bone. full motion of the limbs, yet the spine is undoubtedly broken or crushed, and he will, I fear, die with the symptoms of the last case, and from the same cause — -suppuration within the tube of the spine. "Evening. — He is delirious, and like a man who is good-tempered in his cups. His stools and urine still pass involuntarily. Pulse 130, weak. "I7th, — It has been necessary to tie him down in bed. He now appears dying. His breathing is very quick and laboured ; his pulse hurried ; his countenance is sunk, and his tongue is covered with a brown fur. About an hour before death a change took place from that happy delirium, and groaning as in much pain, he fell insensible and died. The eleventh dorsal vertebra (sic) was fractured in its body. The spinous process of the same vertebra was crushed. The spinal marrow did not appear to liave suffered mechanically, or to have been crushed. Pus, thick in consistence and of a greenish colour, lay betwixt the sheath and the spinal marrow. There was an effusion of serum betwixt the membranes of the brain." It is evident, on carefully examining the specimen, that the injury has been to the second lumbar, and not to the eleventh dorsal vertebra. The description of the injury, more- over, quite tallies Avith the condition of the specimen, so that this discrepancy cannot be accounted for by any mistake in its identity. It is important to note that this injury has been pro- duced in a different way to that of the previous specimens. From the nature of the accident, the spinal column has pro- bably been injured directly where the man struck his back, also indirectly by its having been bent backwards (not forwards, as in the previous cases). B. C. 1. 4. M. 12. 3. 89. Old-standing" Crushing" Fracture of the first Lumbar Vertebra. — Sections of the last dorsal, first, and part of second lumbar vertebrae — macerated and dried, to show the above injury. The accident happened by a weight of earth falling upon the man's shoulders, and although the spinal cord must have been compressed the patient survived the injury for "a considerable time." The substance of the injured vertebrae seems to have been crushed backwards upon the spinal canal, but the parts have apparently been consolidated. Figured in Bell's ' ' Observ. on Injuries of the Spine and Thigh Bone," plate i. fig. 2. B. C. 1. 4. M. 10. Fractures of the Thorax. 79 3. 90. Old-standing" Lateral Dislocation of the last Dorsal from the first Lumbar Vertebrae. — Lower six dorsal and upper four lumbar vertebrje, from a boy. The specimen is in spirit, and the muscles are cleaned oflf, and the spinal canal laid open from behind to show the results of the above condition. He was knocked down by a stage-coach, and survived the accident eleven months, although quite paralysed in his lower limbs. He died of croup. The vertebrae are completely dislocated laterally. The spinal cord is torn through, and its ends — indicated by bristles — are seen about \h inch apart, embedded in fibrous tissue. Along the front of the preparation a mass of new fibrous tissue unites the bones. Figured in Bell's " Observations on Injuries of the Spine and Thigh Bone," plate ii. figs. 2 and 3. B. C. 1. 4. M. 9. 3. 91. Gunshot Injury of the Spine. — Bodies of two dorsal ver- tebrae— macerated and dried — showing a round bullet embedded at the back of one of them. The injury was received in an encounter with smugglers. The ball perforated the lateral part of the bone, and was stopped by the longitudinal ligament, which it pushed out so as to destroy the spinal cord. The bullet had evidently entered on the right side of the body, and passed backwards. It has penetrated, without fractur- ine;, the cancellous tissue. B. C. xvii. 11. TEACTUEES OF THE THOEAX. FRACTURE OF THE STERKUM. 3. 92. Fracture of the Sternum. — Sternum and costal cartilages of an adult, partially cleaned — in spirit — showing a fracture near the lower end. A stone fell and crushed the man's chest, breaking several ribs, about half-way round. The lung was compressed and bruised between 80 Injuries of Bone. the sternum and vertebra}, and the oesophagus was also bruised. The man died shortly after admission to the Royal Infirmary, Edinburgh. It should be noted that the bone, although broken, is not displaced, and the injury could not be seen from the front, nor, in fact, from the back either, until the soft parts were dissected off to show the fracture below. G. C. 3343. Presented by A. G. Millek, F.R.C.S.E. FRACTUKES OF RIBS. 3. 93. United Fracture of Ribs. — Sternal ends of three ribs of an adult, with costal cartilages — macerated — showing a united fracture in each bone. In each case there is some displacement. In two of the ribs the fracture has taken place about one inch, and in the third about two inches from the cartilage. W. C. G. 2. 3. 94. United Fracture of Ribs. — Two mid-left ribs of an adult — macerated — showing the above. They were taken from the Acropolis of Athens. The bones have been broken about their middle, and have united. From the seat of fracture of the lower rib a connect- ing mass of new bone extends to the upper rib in front of the broken spot. (This bridge of bone has been accidentally broken after death.) G. C. 2076. Frescntcd by Dr Hay, 1840. FRACTUKES OF THE CLAVICLE. 3. 95. United Fracture of the Clavicle— Right clavicle — macerated, showing the above. The bone has been broken very obliquely about the middle, but has united, with no other displacement excepting that of over-riding. W. C. G. 8. Fractures of the Clavicle. 81 3.96. United Fracture of the Clavicle. — Right clavicle macerated, showing the above. The bone has been broken obliquely about the middle, and has united with over-riding, and with some depression of the outer fragment. B. C. I. 1. M. 5. 3. 97. United Fracture of the Clavicle.— Plaster of Paris cast of a right clavicle, which had possibly sustained a fracture at the junction of the inner and middle thirds, with absorption at the fractured spot. Absorption of this kind is, however, not common, and is difficult to explain. G. C. 3248. Presented by Charles W. Cathcart, F.R.C.S.E., 1890. 3. 98. United Fracture of the Clavicle.— Plaster of Paris cast of the rightclavicle of an adult, showing the above. The break has occurred between the outer and middle thirds, and the union has taken place with distinct callous and some depression of the outer fragment. G. C. 3249. Presented hij Charles W. Cathcart, F.R.C.S.E., 1890. 3. 99. United Fracture of the Clavicle.— Plaster of Paris cast of a left clavicle, showing the above. The bone had been broken near the junction of the outer and middle thirds, and had united with considerable callous. G. C. 3093. Presented hy Charles W, Cathcart, F.R.C.S.E., 1889. 3. 100. United Fracture of the Clavicle.— Left clavicle- macerated — showing the above. The break has taken place obliquely near the junction of the outer and middle thirds. There is over-riding and distinct callous. B. C. I. 1. M. 6. F S2 Injuries of Bone. 3. 101. United Fracture of the outer end of the Clavicle. — Plaster of Paris cast of a left clavicle, showing the above. The bone has been broken through at the line of attach- ment of the trapezoid ligament. The outer fragment shows the characteristic displacement forwards without any depression. G. C. 3251. Presented by F. M. Caikd, F.R.C.S.E. FEACTUKES OF THE SCAPULA. 3. 102. Ununited Fracture of the Acromion Process and United Fracture of the Vertebral Border.— Left scapula of an adult — macerated — showing the above. The acromion process has been separated from the spine, and the margins of the bone are thickened where the pieces meet. The fracture at the inferior angle has extended to the vertebral border, and the pieces have united with considerable displacement. The injury to the acromion might, from the position and direction of the line of separation, have been an ununited epiphysis, but the raised margins of bone and the presence of a fracture at another part of the bone render the theory of fracture more probable. B. C. I. 1. M. 7b. 3. 103. Supposed Fracture of the Acromion Process of the Scapula. — Right scapula — macerated — showing an irre- gular groove between the acromion process and the rest of the bone. This is possibly a late union of the epiphysis. B. C. I. 1. M. 7. FRACTURES OF THE HUMERUS. 3. 104. Recent Fracture through the Anatomical Neck with Comminution of the Bone below.— Outer portion of a Fractures of the Humerus. 83 left scapula and the upper end of a humerus, with the muscles dissected off and the capsule laid open, so as to expose the joint from the front — in spirit — showing the above injury. The patient, Mary Kidd, set. 55, fell down some stone steps on Saturday night, December 29, 1827. When admitted to the Royal Infirmary, Edinburgh, on January 2, 1828, the following report was made : — ' ' The whole of the left upper extremity is ecchymosed and much swollen ; there is a distinct crepitus near the upper end of the humerus, and during the rotation of the bone the head remains motionless, the lower end of the bone is drawn in towards the chest, pulse 100 and feeble, belly costive, tongue furred, the pain at the upper part of the limb has been constantly upon the increase." On the 4th of January the patient was observed to be labouring under the symptoms of delirium tremens ; she had been constantly talking during the preceding night, and did not answer questions ration- ally ; had much tremor of the hands, pulse 90, skin cool, tongue moist. These sj'mptoms continued with considerable variation and with occasional intermissions until about the 18th, when a considerable slough was observed on the sacrum and right buttock. This increased pro- gressively notwithstanding the use of every means to protect the parts from pressure, and she expired on the 28th January. The head of the bone has been separated along nearly the line of the anatomical neck, and the tuberosities and upper part of the shaft have been severely comminuted. This has probably been the result of a blow directly upon the shoulder. G. C. 1100. Presented by Sir George Ballingaij.. 3. 105. Recent Fpactupe through the Anatomical Neck with Comminution of the Tuberosities.— Upper end of a left humerus, with the muscles dissected off — in spirit — showing the above injury. The head is separated by a fracture following the line of the anatomical neck, and the greater tuberosity is comminuted. This also has probably been the result of a blow directly upon the shoulder. G. C. 2657. Fraented by Dr Watson. 3. 106. Fracture through the Anatomical Neck and greater Tuberosity. — Head and tuberosities of a right 84 Injuries of Bone. humerus, broken off irregularly from the shaft of the bone — macerated. The patient, John Locke, ?et. 64, fell over a parapet at Stockbridge, and besides this injury sustained a compound fracture of the elbow joint. The arm was amputated at the shoulder joint a few hours after the accident by Sir George Ballingall, and the patient recovered without a bad symptom. The fracture has passed between the anatomical and sur- gical necks on the outer side, and through the anatomical neck on the inner side of the bone, i.e. in a line corresponding to that of the epiphysial junction in a young subject. The rari- fication of bone round the seat of fracture makes it appear as if the patient had survived the injury for some weeks, and as if this piece had had a vascular supply. G. C. 744. Presented by Sir Geoege Ballingall. 3. 107. Fracture throug-h the Anatomical Neck and greater Tuberosity. — Left humerus — macerated — showing the above injury. The fracture, as in the previous specimen, has passed between the anatomical and surgical necks on the outer side, and through the anatomical neck on the inner side of the bone. There has been no union, but there are indications of periostitis on the upper piece at the outside, and on the lower fragment down nearly to the elboAv joint. The patient had therefore probably survived the injury several weeks. G. C. 918. Presented h>i Sir George Ballingall. 3. 108. United Fracture throug-h the Anatomical Neck and g-reater Tuberosity. — Left humerus of an adult, probably a woman — macerated — showing the above. The line of fracture has evidently been similar to that in the last two specimens, i.e., between the two necks on the outer side, and along the line of the anatomical neck on the inner side. The broken bone has united without thickening, but Fractures of the Humerus, 85 with distinct displacement. The upper fragment is tilted outwards and is rotated inwards. The articular surface of the head thus looks more backwards and less upwards than in a normal bone. The greater tuberosity recedes inwards from, instead of projecting beyond, the line of the outer surface of the shaft. The articular surface has been injured apparently ^o,s^ mortem. G. C. 3213. 3. 109. United Fracture through the Surg"ical Neck. — Right humerus — macerated — showing the above. The line of fracture has passed through the upper part of the surgical neck. The upper fragment has been tilted out- wards and rotated inwards in a way similar to that seen in the previous specimen. There is some irregularity in the bicipital groove and on the inner side, but the bone at the seat of fracture is quite smooth on th« outside. G. C. 3214. S.'^llO. United Fracture throug-h the Surgical Neck.— Plaster of Paris cast of a left humerus, showing the above. The line of fracture has apparently been at the upper part of the surgical neck, but the exact position is hidden by a considerable quantity of bone thrown out round about it, G. C. 3253. Presented by Charles W. Cathcaet, F.R.C'S.E., 1890. 3. 111. United Fracture through the Surgical Neck.— Plaster of Paris cast of a left humerus, showing the above. The line of fracture has passed somewhat obliquely down- wards and backwards from the bicipital groove. The upper fragment has been rotated inwards and tilted forwards so as to meet the lower fragment at an obtuse angle projecting forwards. The articular surface of the humerus is thus correspondingly altered in position. G. C. 3252 Presented Uj Charles W. Cathcakt, F.R.C- E., 1890. 86 Injuries of Bone. 3. 1 1 2. United Oblique Fracture through the Surg-ical Neck. — Right Immerus — macerated — showing the above. The line of fracture beginning behind about an inch below the head has run obliquely downwards and forwards for about two inches and a half. There is some overriding of the frag- ments, and the upper one is tilted forwards and outwards, and is rotated inwards. B. C. I. 1. M. 49. 3. 113. Recent Fracture of the Shaft.— Portions of a recently fractured humerus, sawn up and macerated. G. C. 336a, Presented by Sir George Ballingall. 3. 114. Uniting- Fracture at the Lower End of the Shaft. — Lower portion of a right humerus — partially macerated and in spirit — showing the above. There has been a comminuted fracture in process of union. A large quantity of forming cancellous bone (provi- sional callous) surrounds the broken ends. G. C. 173. 3. 115. Recent Compound Fracture of the lower End.— Eight upper limb of a boy aged six years — in spirit — showing severe laceration, which accompanied the above. The boy's arm was run over by a heavy cart. The soft parts were greatly lacerated, and the bone split as well as fractured. G. C. 2669. Presented by W. Finlay, F.R.C.S.E. 3. 116. United Oblique Fracture through the upper por- tion of the Shaft. — Left humerus — macerated — showing the above. The line of fracture beginning behind about an inch below the head has run downwards and forwards for about three Fractures of the Humerus. 87 inches and a half. The upper fragment is tilted slightly forwards, and is rotated inwards. B. C. I. 1. M. 50. 3. 117. Badly united Fracture through the upper part of the Shaft. — Right humerus — macerated — showing the above. The upper fragment is rotated inwards, and is tilted forwards and outwards. The axis of the lower fragment has also been altered, so that the two pieces meet at an obtuse angle, directed outwards. They have united, but with considerable callous thickening between the broken ends. B. C. I. 1. M. 48. 3. 118. Badly United Comminuted Fracture through the Upper End. — Left humerus — macerated — showing the above. The upper portion has been split and comminuted, and of the fragments thus formed there are three main pieces, viz. — an anterior, bearing chiefly the bicipital groove ; a posterior, bearing the head ; and jambed between these two a smaller fragment on the inner side. The lower portion of the bone has a pointed upper extremity, and the appearances are such as might have been produced by the impaction of the lower portion into the upper, thus splitting and comminuting it. The bone has been in process of healing, but as the new bone is still porous, it has evidently not had time to consolidate. G. C. 2784. 3. 119. United Fracture above the Insertion of the Deltoid. — Anterior half of the upper end of a left humerus — macerated — showing the above. The broken ends of the bone have been displaced, so as to form with one another an obtuse angle, pointing forwards. There is very little thickening at the seat of fracture, and the medullary cavity has been restored. B, C. I. 1. M. 51a. 88 Injuries of Bone. 3. 120. United Fracture below the Insertion of the Deltoid. — Plaster of Paris cast of a left humerus, showing the above. The lower fragment has been displaced somewhat in front, and to the inner side of the upper, and both have been tilted, so that at the point of junction the fragments form an obtuse angle, directed forwards and outwards. G. C. 3254. Presented hy Charles W. Cathcabt, F.R.C.S.E., 1890. 3 121. United Fracture below the Insertion of the Deltoid. — Lower part of a right humerus, sawn in lateral halves, and macerated to show the above injury. The lower fragment has been displaced forwards. !New bone surrounds the broken ends, and the medullary canal at the seat of fracture is occupied by cancellated tissue. W. C. G. 6. 3. 122. Badly United Fracture below the Insertion of the Deltoid. — Part of the shaft of a right humerus — macerated — showing the above. The lower fragment is behind the upper. The two are united with much intervening callous at a very obtuse angle, the apex of which points outwards. G. C. 3450. Presentedhj Macdonald Brown, F.R.C.S.E., 1892. 3. 1 23. Ununited Fracture at the Insertion of the Deltoid. — Plaster of Paris cast of the left humerus of David Living- stone, the great African missionary and traveller, showing the position of the ununited fragments. Many years before his death, his arm had been crushed by a lion and the fracture had remained ununited. The upper fragment has been considerably atrophied, and is rotated inwards. G. C. 2433. Presented ly Sir William Ferguson. Fractures of the Humerus. 89 3. 124. Ununited Fracture at the Lower End of the Shaft. — Left humerus of an adult woman — macerated — showing the above. The patient, aged 40, after having been treated in the Royal Infirmary, Edinburgh, for fractured humerus was discharged. On August 24, 1825, she was re-admitted for pain and a iluctuating swelling in the region of the fracture. Next day the swelling was incised, and a great quantity of thin, glairy fluid was discharged. On the 10th of September, symptoms of septicaemia appeared, the wound inflamed and suppurated, and on the 16th September she died suddenly, apparently much exhausted. The adjacent surfaces of bone are smooth, but the provisional callous on the inner and front part seems to have united round the bone before death. The surface of the bone above and below the fracture is roughened and covered by new periosteal outgrowth in a way common in septic irritation. This seems to have been a case of ununited fracture with serous exudation round the broken ends, and septicaemia following the incision. The small part of callous union pro- bably occurred after the second admission to the Infirmary. G. C. 1011. 3. 125. United Fracture above the Condyles.— Adjacent portions of the right humerus and ulna of an adult — macerated — showing the effects of the above injury. The bone is broken about one and a half inches above the condyles. The lower fragment has been displaced forward, and over-riding has occurred. Inflammation has ensued in and around the elbow joint, and this has led to alteration of the articular surfaces and anchylosis. B. C. I. 1. M. 47. 3. 126. United Fracture through the Coronoid Fossa.— Plaster of Paris cast of the lower end of the right humerus of an adult, showing the above. The line of fracture has passed through the inner condyle, 90 Injuries of Bone. across the olecranon and coronoid fossae, and has terminated about half an inch above the outer condyle. G. C. 3092. Presented hy Charles W. Cathcap.t, F.R.C.S.E. . FKACTUKES OF THE KADIUS AND ULNA. 3. 127. Badly United Fracture of the Radius and Ulna. — Left radius and ulna of a young person — macerated — show- ing the above. The bones have been united at a considerable angle, and there is callous thickening round the seat of fracture, especially on the radius. The epiphyseal lines are apparent at the lower end of both bones on the dorsal aspect. This has probably been a fracture of the radius and a green- stick fracture of the ulna. F. P. C. 74. Presented hy Professor John Thomson. 3. 128. Fracture of the Bones of the forearm, Radius ununited. — Bones of the right forearm of an adult macerated. The ulna, fractured a little below the middle, is united in bad position. The lower fragment is displaced inwards from the upper, and is somewhat rotated inwards on its own axis. The head and styloid processes are greatly altered, apparently by arthritis deformans. The radius has an ununited fracture about the middle. The broken ends are enlarged and irregular, and their contiguous surfaces are rough. At the lower end the radius has been broken about half an inch above the articular surface, and the lower fragment has been displaced outwards and backwards, but without much rotation backwards. The styloid process has, however, thus been raised above the level of that of the ulna. This injury might be called a form of Colles' fracture. G. C. 3449. Presented by Macdonalu Brown, F.R.C.S.E. Fractures of the Badnts and Ulna. 91 3. 129. United fracture of the Radius between the attach- ments of the Pronator Radii Teres and Supinator Brevis, — Plaster of Paris cast of a right radius showing the above. The fracture has united in a bad position in two ways. Besides a distinct angular deformity there has been a relative rotation of the two fragments ; the upper is in supination, and the lower in pronation. This latter deformity can only be prevented by treating the fractured limb in the supine position. G. C. 3089. Presented by Charles W. Cathcart, F.R.CS.E. 3. 130. Fracture of the Radius, below the Pronator Radii Teres. — Right radius — macerated — showing the above. The fracture has been badly united. The ends overlap, and the upper fragment has been drawn inwards, and has evidently been united to the ulna, while the lower fragment is somewhat pronated. W. C. G. 17. 3. 131. Fracture of the Radius beween the Pronator Radii Teres and the Pronator Quadratus. — Longitudinal section through a right radius — macerated — showing the above. The fragments overlap, and the lower one has been drawn inwards, and is pronated. The medullary canal where exposed on the overlapping fragments has been closed in, but it has not been re-established in the interior. F. P. C. 75. Presented bij Professor John Thomson. 3. 132. United Fracture of the Radius near its Lower End. — Skeleton of a left forearm — cleaned and dried, showing the above. The radius at the seat of fracture, i.e. about two inches 92 Injuries of Bone. above the lower end, is brought near the ulna. The articular surface for the carpus looks slightly backwards, and the styloid process has been displaced upwards. These alterations resemble those found in Colles' fracture, which, however, is usually at a lower level. The ulna at its lower end is bent away from the radius, and its styloid process projects unduly. G. C. 278.5. Presented by Johnson Symington, F.R.C.S.E. 3. 132a. Structure and Arrangfement of Parts concerned in Colles' Fracture. — Skeleton of a left hand and wrist, and sections of a left radius, to illustrate the above. G. C. 3271. Presented by .Johnson Symington, F.R.C.S.E. 3. 133. Recent Compound Colles' Fracture.— Right hand and forearm of a young woman — in spirit, with the tendons dissected at the back, to illustrate the above. The patient while drunk had been tripped up on the street. Acute septic inflammation ensued, and was followed by spreading gangrene, for which amputation through the upper arm became necessary. For many days after the amputation her life was in danger, but she ultimately made a good recovery. The wound made by the lower end of the ulna is shown in front. The lower end of the radius has been comminuted and the styloid process of the ulna broken off. G. C. 3271. Presented by Charles W. Cathcart, F.R.C.S.E. 3. 134. Badly united Colles' Fracture.— Skeleton of the left forearm of an old person — cleaned and dried, showing the above. The radius has been fractured about half an inch above its lower end ; the carpal articular surface has been forced back- wards and upwards, and looks obliquely backwards. Its styloid process is now on a level with that of the ulna. The carpus and lower fragment of the radius thus project Fractures of the Badius and Ulna. 93 backwards and towards the radial side ; the lower end of the upper fragment projects forwards. Owing to this and to the backward rotation of the lower fragment of the radius the usual hollow on the front of the lower end of the bone has disappeared. The styloid process of the ulna relatively projects. The head is altered. The olecranon process has been broken and is partially united. G. C. 2786. Presented by Johnson Symington, F.R.C.S.E. 3. 135. United CoUes' Fracture.— Skeleton of the left hand and forearm of an old woman — cleaned and dried, showing the above. The patient was an old woman, the most of whose bones were in a condition of senile osteo-malacia. The lower end of the radius has been rotated backwards, and has been forced to the radial side. The styloid process of the radius is on the level of that of the ulna. There were no adhesions either in the joints or in the synovial sheaths of the wrist. The flexor carpi ulnaris tendon is in its usual place. G. C. 3220. Presented hij Charles W. Cathcart, Esq., F.R.C.S.E. 3. 136. United Colles' Fracture. — Bones of a left forearm — macerated — to show the above. The lower end of the radius is displaced outwards and backwards, but with less rotation backwards than is usual. The lower fragment has probably been comminuted. The appear- ances are those of an imperfectly reduced Colles' fracture. Sir Charles Bell describes this specimen as " a fracture of the radius near the wrist. This is a very common accident, and is apt to be mistaken for a dislocation or sprain." B. C. I. 1. M. 53. 94 Injuries of Bone. 3. 137. United Colles' Fracture. — Eight radius and ulna of an old woman — macerated, showing the above. The displacement is comparatively slight. The styloid process of the radius is however slightly pushed upwards towards the elbow, and the articular surface looks now directly downwards in the axis of the bone, instead of, as normally, forwards. G. C. 3221. Presented hij Charles W. Cathcart, F.R.C.S.E. 3. 138. United Colles' Fracture. — Left hand of an adult dissected to show the relations of the tendons at the wrist after the above injury — in spirit. The deformity is characteristic. The tendon of the extensor carpi ulnaris has been dislocated outwards, and lies external to the head of the ulna. In every other respect the tendons are in their normal position, and they are free from adhesions. G. C. 3219. Frescnted by Ciiarlks W. Cathcart, F.R.C.S.E. 3. 139. Badly united Colles' Fracture.— Plaster cast of the left hand and part of the forearm of a man showing the characteristic deformity of a Colles' fracture. The injury had occurred several years before the cast was taken, and the hand though deformed was quite useful. G. C. 3290. Presented hy Chaelks W. Cathcart, F.E.C.S.E. 3. 140. Badly united severe Colles' Fracture.— Plaster cast of a right hand and wrist from a case of Colles' fracture, produced in an unusual way. The patient was a workman engaged at tlie building of the Forth Bridge. He was holding the lever of a punching machine, when it was allowed bj accident to give his hand a sudden and violent thrust directly Fractures of the Hadms and Viva. 95 liackwards. In consequence the radius was broken. The fracture was at first enclosed in splints, without being reduced, and the patient was sent by the surgeon of the works to a surgeon in Edinburgh. The latter, on the supposition that the fracture had been set, left it in the splints, and lastly, the patient, by some mistake, did not return for six weeks to have the splints removed. In consequence the hand became practically useless. Refracture was found impossible, and massage did no good. It will be observed that there is little or no lateral displacement. This confirms the view that the usual presence of lateral displacement is due to the direction of the breaking strain. G. C. 3100. Presented by Charles \V. Cathcaet, F.R.C.S.E. 3. 141. United Fracture of the Ulna.— Lower part of a right ulna, macerated, showing a fracture united with some displace- ment and considerable callous. From the diminution of the articular surface the range of pronation and supination must have been greatly diminished. B. C. I. 1. M. 54. 3. 142. United "Smith's" Fracture.— Right radius and ulna, carpus, and part of metacarpus — macerated, showing the above. There has been a fracture through the lower end of the radius, just above the articular surface, with a displacement similar to that seen in Colles' fracture, only forwards instead of backwards. The styloid process of the radius is at a higher level than that of the ulna. The articular surface of the radius looks now very obliquely forwards. The normal hollow, just above the articular surface in front, is increased, while there is a marked projection at a corresponding place at the back. There are deep grooves on the back of the radius for the tendons of the extensor secundi internodii pollicis and the extensor indicis. This fracture is produced by a forcible bending of the hand forwards, i.e. in a direction the reverse of that in which Colles' fracture is produced. Gr. C. 3551. Presented by CBAHLESi W. Cathcart, F.R.C.S.E., 1893. 96 Injuries of Bone. 3. 143. Compound Comminuted Fracture of the Hand and Forearm. — Shattered portions of the bones of the hand and forearm of a woman — macerated and mounted on a board to illustrate the above. The arm was crushed by machinery, and was amputated at the shoulder but twenty-four hours after the accident. Suppuration set in, and extended below the pectoralis major and latissimus dorsi, and the patient died. G. C. 1225. Presented by Dr John Campbell, F.R.C.S.E., 1828. GUNSHOT FRACTURES OF THE BONES OF THE UPPER LIMB. 3. 144. Gunshot Fracture of the Clavicle and Scapula.— Right scapula and outer part of clavicle — macerated, showing a bullet lodged in the supra-spinatus fossa, after having penetrated from the front. " The musket ball is lodged in the back of the scapula. This I took from the body of Captain . The ball entered in the breast, broke the end of the clavicle, entered the chest, and went across the lungs, broke a rib upon the back part, stuck in the scapula, the spent ball being nearly divided in two by the spine of the scapula. I was present when he was brought ashore at Portsmouth in a very exhausted condition, and labouring in his breathing. He died the next day, which was the 12th from his receiving the wound. On opening the body I was astonished at finding the quantity of serum which poured out from the chest, as out of a barrel. The lungs were condensed and gorged with blood. He would have been much relieved by the operation of Paracentesis." See "Operative Surgery," 2nd edition, in the description of Plates IV. and XIII. The spine and adjacent parts of the scapula have been splintered by the bullet. Its extraction would have been attended Avith great difficulty from its having a dumb-bell shape, with the neck lying in the aperture in the bone, and each end larger than the aperture. The sternal end of the clavicle has been splintered off. B. C. xvii. 17. 3. 145. Gunshot Wound of the Chest and Scapula.— Oil Ghinshot Fractures of the Upper Limb. 97 painting by Sir Charles Bell of Captain from whom the previous specimen was taken. The painting shows where the bullet entered in front. B. C. XVII. 18. 3. 146. Gunshot Wound of the Humerus.— Oil painting by Sir Charles Bell of a soldier, wounded as above at Coiunna. The ball struck the head of the os humeri, shattered it,, passed through, and wounded a rib. Amputation was per- formed, but the patient sank from loss of blood. B. C. XVII. 22. 3. 147. Gunshot Wound of the Head and Tuberosities of the Humerus. — Left humerus — muscles cleaned off and in spirit, showing the above. Sir Charles Bell says : " This is the case which gave rise to my reflections on the propriety of the excision of the bone. The patient was one of those soldiers brought home from Corunna to Haslar Hospital, while I was there studying the subject. When I put my hand on this man's shoulder the bone felt like a bag of sand. 'Now,' said the operator, ' this we consider a proper case for amputation at the shoulder joint ;' and he proceeded to the operation, which he performed with remarkable dexterity. But afterwards, when I had an opportunity of reflecting on a variety of the same class of cases, I saw the impropriety of this proceed- ing." (See " Operative Surgery," second edition, page 473, and the expla- nation of Plates iv. and vii.) The head of the humerus is split off, and the tuberosities and upper part of the shaft are severely comminuted. One large fragment of the shaft has been loosened but not detached. B. C. XVII. 21. 3. 148. Gunshot Wound of the Humerus.— Photograph from the drawing by Sir Charles Bell of the patient from whom the foregoing specimen was taken. G. C. 3558. 98 Injuries of Bone. 3. 149. Gunshot Fracture of the Upper End of the Humerus.— Right humerus — macerated, showing the above. Sir Charles Bell says : " I received a man who had got a musket shot through his shoulder at Brussels. The bones were shattered, and I resolved to make a free incision, and saw off the head of the humerus. I had pro- ceeded so far as to extract the fractured portions, when I was called upon to consult by two inspecting surgeons who had that moment come into the room. They induced me to amputate at the shoulder joint, which I regretted, as it Avas against my own principles." The bullet has split off a fragment, carrying the upper end of the bicipital groove, the lesser tuberosity, and the front of the greater tuberosity, and has thus freely exposed the cancellous texture at the back of the bone. B. C. XVII. 20. 3. 150. Gunshot Fracture of Acromion Process.— Portions of the acromion process of a right scapula — macerated. The portions are those which were extracted before amputa- tion of the arm, the humerus of which forms the foregoing preparation. B. C. xvii. 19. 3. 151. Excision of the Head of the Humerus for Gun- shot Injury. — Plaster cast of the right arm and half of the neck and thorax of a soldier, on whom the above operation had been successfully performed. Sir Charles Bell says : " This is the cast of the shoulder of a soldier who had suffered that operation, which I proposed as a substitute for the amputation of the shoulder joint. He had received a ball in the head of the humerus. The surgeon, instead of amputating, as in the former instances, made a free incision, and sawed off the shattered bit of bone. This was after my observations made at lecture and in publica- tions. The surgeon, Mr , brought this cast here to Windmill Street, on his return from America, and presented it to me as a practical example of the correctness of my doctrine. He afterwards communicated it to others." B. C. XVII. 23. Gunshot Fractures of the, TJ^'per Limh. 99 3. 152. Gunshot Fracture of the Shaft of the Humerus. — Detached upper end of a left humerus — macerated, showing the above. The patient was a soldier who fought at Waterloo. The bone has evidently been comminuted as well as broken, and a fissure is seen in the bicipital groove. Near the seat of fracture are marks of inflammation, and a small piece of necrosed bone has been in process of separation. F. P. C. 203. Presented by Professor John Thomson. 3. 153. United Gunshot Fracture of the Upper Part of the Shaft of the Humerus. — Sections of the upper part of a right humerus — macerated, showing the above. Chronic ostitis and periostitis have been present, and have led to enlargement and sclerosis of the upper part of the shaft. From the inner lip of the bicipital groove a mass of bone projects upwards and forwards. G. C. 669. Presented hy Adam Hunter, F.R.C.S.E., 1824. 3. 154. Recent Comminuted Gunshot Fracture of the Shaft of the Humerus. — Lower portion of a left humerus, shattered by a musket ball — macerated. The patient was a soldier who fought at Corunna. Amputation was performed, but Sir Charles Bell thought improperly so, as " the pieces ought to have been taken away by incision." (See Sir Charles Bell's " Operative Surgery," 2nd edition, p. 471.) The bone, where struck, has been broken in several large pieces, and one or two fissures run down into the lower fragment. B. C. xvii. 24. 3.155. Gunshot Wound of the Humerus.— Oil painting by Sir Charles Bell of the patient, before amputation, from whom the foregoing specimen was taken. B. C. xvii. 25. 100 Injuries of Bone. 3. 156. Gunshot Fracture of the Shaft of the Humerus. — Lower half of a left humerus — macerated, showing the effects of septic osteo-myelitis following the above. The patient was a soldier who was wounded at Waterloo. The bone at the seat of fracture has necrosed, and has been in process of separation. Lower down the opening up of the vascular channels shows that there has been inflammation of the periosteum, although not with the formation of any new bone. F. P. C. 205. Presented by Professor John Thomsoic. 3. 157. Gunshot Fracture of the Shaft of the Humerus. — Portion of a humerus — macerated, showing the effects of the above. The patient was a soldier who fought at "Waterloo. There has evidently been septic osteo-myelitis. A portion of the bone, smoother and whiter than the rest, has necrosed. At other places new bone has been thrown out from the broken surface of the bone, from the periosteum, and in the medullary cavity. F. P. C. 204. Presented by Professor John Thomson. 3. 158. Old-standing" Gunshot Fracture of the Lower End of the Humerus. — Lower end of a left humerus — macerated, showing the effects of the above. The wound was received at Waterloo by a soldier who fought there. He sank exhausted by hectic fever and diarrhoea thirteen months after the battle. This specimen was figured in Hennen's " Military Surgery," 2nd edition, plate i. fig. 3, as an illustration of the bad effects of the impaction of a fragment of bone into the medulla ; also of Nature's attempt to bridge over the injured part by new bone formation. The features of the specimen would, however, be now explained by septic inflammation of the bone and soft parts, with subsequent reparative changes. Gunshot Fractures of the Upper Lhiib. 101 There has been considerable thickening at the seat of fracture. The broken ends are separated by a considerable interval, which is bridged over by two necks of bone. A fragment lies embedded, but movable, at the place where these two necks blend with the upper part of the shaft. F. P. C. 207. Presented by Professor John Thomson. S. 159. Old-standing" Gunshot Fracture of the Shaft of the Humerus. — Oil painting by Sir Charles Bell, showing the above. The patient was an officer, who fought at the battle of Waterloo. The painting was made two years after the injury had been received. Necrosis had taken place. B. C. xvii. 26. 3. 160. Gunshot Fracture through the Lower End of the Humerus. — Lower end of a left humerus — macerated, showing the effects of the above, some time after receipt of the injury. The patient was wounded at Waterloo. Some fragments of white necrosed bone are seen at the broken margin. They have been in process of separation, and the bone below shows signs of periostitis. F. P. C. 206. Presented hij Professor John Thomson. 3. 161. Gunshot Injury of the Elbow.— Oil painting of the arm of an officer, by Sir Charles Bell. He " came to me to have his arm amputated. A musket ball is lodged in the elbow joint, the nerves were cut, and the arm asleep, shrunk, and cold." B. C. XVII. 27. 3. 162. Abscess in the Shaft of the Humerus following- Gunshot Injury.— Section of the lower end of a right 102 Injuries of Bone. humerus — macerated, showing expansion of bone near the lower end. Some years before the preparation was obtained the bone had been fractured by gunshot. The bone is expanded, and the cavity, about three inches from the lower end, is smooth, probably the result of a slowly forming abscess. B. C. xvii. 28. 3. 163. Shattering* of the Hand from the Explosion of a Gun. — Skeleton of the left hand and lower part of the fore-arm of a young man — macerated, showing the above. In consequence of the bursting of a fowling-piece, his hand was shattered, and a primary amputation through the fore-arm was performed. From this the patient made a good recovery. The first phalanx of the thumb has been injured; the last and part of the second phalanx of the third finger, as well as the whole of the little finger, except the base of its metacarpal bone, have been lost (perhaps blown away). Every carpal bone except the trapezium and semi-lunar has been fractured. G. C. 917. Presented by Sir George Ballingall. 3. 164. Shattering" of the Hand from the Explosion of a Gun. — Lower ends of a left radius and ulna, with remains of carpus and metacarpus, showing the above. The subject, William Gardner, aged 19, received the injury by the bursting of a fowling-piece on 8th May 1828. The metacarpal bones of the left hand Avere fractured near their carpal extremities; their heads, with the exception of that of the thumb, were dislocated at their articulation with the bones of the carpus, the anterior row of which was very much exposed and loosened from its connections with the other ; the soft parts on the back, but particularly on the palm of the hand, were extensively lacerated ; haemorrhage trifling. See Sir George Ballingall's Clinical Lecture, No. 4, page 6. G. C. 1118. Presented bij Sir George Ballingall. Fracture of the Pelvis. 103 FKACTURE OF THE PELVIS. 3. 165. United Fracture througrh the Ala of the Ilium.— Pelvis of an adult man — macerated, showing the above. The ala of the left ilium has been broken across, and there has been a great deposit of new bone along the line of fracture. B. C. I. 1. M. 1. FKACTUKES OF THE FEMUE. 3. 166. Attachment of the Capsule of the Hip Joint to the Femur. — Upper end of a femur — muscles dissected off — in spirit, showing the above. The reflected portions of ligament which run along the neck towards the head are well shown. They carry blood- vessels, hence, when they are torn through in intra-capsular fracture, the nutrition of the upper fragment is seriously impaired. G. C. 3552. Presented by Johnson Symington, F.R.C.S.E., 1893. 3. 167. Structure of the Upper End of the Femur.— Transverse section through the upper end of a femur — macerated , showing the above. This view shows the relations of the neck as bearing upon impaction. G. C. 3553. Presented by Johxson Symington, F.R.C.S.E., 1893. 3. 168. Recent Intracapsular Fracture of the Neck.— Upper part of the left femur of an adult — macerated, showing the above. The line of fracture is very irregular, and several pieces of bone are wanting along its anterior and upper part. The outer fragment seems to have been impacted into the inner or head 104 Injuries of Bone. fragment, the interior of which has a crushed look, and shows at the front a small impacted fragment still in position. G. C. 637. Presented by John Hexry Wishaet, F.R.C.S.E. 3. 169. Somewhat recent Intracapsular Fracture of the Neck. — Upper end of the left femur of an adult — macerated, showing the above. The line of fracture has been nearly vertical. Thus above it has begun close to and involves the head, and below it has passed out on the neck. Several pieces of bone are wanting at the upper part of the line of fracture. From the roughness of the front of the neck it would appear that the patient survived the injury for some weeks. There is some absorption on the front of the upper fragment, but there has been no attempt at union. G. C 727. 3. 170. Somewhat recent Intracapsular Fracture of the Neck. — Head and part of the neck of a femur detached by the above form of fracture — in spirit. The patient lived six weeks after the accident. The line of fracture has been oblique, passing close to the head above, and leaving a portion of the neck below. B. C. I. 1. M. 13. 3. 171. Somewhat recent Intracapsular Fracture of the Neck. — Upper end of the left femur of an adult — muscles partly cleaned off— in spirit. The patient lived for six weeks after the accident. The broken surfaces of the cancellated tissue are covered with lymph, but there is no appearance of union. G. C. 2658. Presented by Dr Watson. Fractures of the Femur. 105 3. 172. United Intracapsular Fracture of the Neck. — Posterior half of the upper end of a right femur, muscles dissected off — in spirit, showing the above. "An enfeebled lady, aged 77 (November 1821), in attempting to walk from her bedroom to an adjoining apartment, slipped her foot suddenly and unexpectedly over the ledge of a landing of a flight of stairs, and immediately fell on the right hip. She attempted to rise, but found that she had completely lost the power of motion in the limb of that side. Her servants, on coming to her assistance, found her sitting on the landing-place, her feet resting on the step below. She was immediately conveyed to bed, but being in comparatively little pain, and it being late in the evening, no medical assistance was required till next morning. I found her in the position in which she had remained during the night, resting upon her back, the right limb a little bent and apparently shortened about an inch and a half, the knee and toes con- siderably everted, the heel resting in the hollow between the ankle and the tendo-achilles of the left leg. She made no complaint, but of inability to move the leg, but all attempts to rotate the thigh occasioned consider- able pain in the situation of the trochanter major, as did also the extension of the limb to bring the malleoli-interni together, which was readily accomplished, but retraction immediately took place, and the leg returned to its original position. No crepitus could be distinguished. Judging from the history and appearances of the case, fracture of the neck of the femur had taken place, and her friends were apprised of the helpless state to which, in all probability, she would be reduced, from no complete re-union being expected. The treatment was therefore very simple. The tipper part of the thigh was frequently fomented ; a broad firm bandage was constantly worn from the knee along the thigh and encircling the body. The limb was supported with pillows, and every attempt made to keep it extended, and the heel in apposition. Under this plan, she remained about five months, occasionally changing from her bed to a sofa. She then began to make some partial use of the leg, and, with the assistance of crutches and gently resting on the toes, she was enabled to move through the room. She ultimately laid aside the crutches, and walked with the assistance of a stout stick. She also, by and by, relinquished the use of the stick, and with the aid of a very high-heeled shoe she was enabled in the course of a year to walk with great facility through her house, and for more than a twelvemonth before her last illness to descend and ascend daily from one flat of her house to another to and from dinner, the knee and foot continuing considerably turned out, and the leg shortened upwards of an inch. In November 1823 she was seized with an aff'ection of the brain, which proved fatal in April 1824." This would seem to have been an impacted intra-capsular fracture of the neck of the femur, for the following reasons, Vu,. 1. The injury was apparently calculated to produce 106 Injuries of Bone. impaction. 2. Crepitus, although looked for, was absent immediately after the accident, although against this it is right to set the shortening, which could apparently be overcome. 3. The great shortening of the neck and its impaction into the head are distinctly seen, especially above, while there is no appearance of impaction of the neck into the great trochanter. As is usual in impaction near the head, the outer fragment has been driven into the inner one. The capsule seems thickened. The lower fragment has been everted, and the trochanter is almost on a level with the head. The bone is condensed in the head and at the line of fracture. G. C. 746. Presented &2/ James Begbie, F.R.C.S.E., 1825. 3.173. United Intra-capsular Fpaeture of the Neck.— Anterior half of the preceding specimen, muscles dissected off — in spirit, showing the above. In addition to indications of impaction seen also in the previous specim.en, this one shows in another way the eversion which was present. The head has been pushed back from the front of the neck, thus allowing the upper end of the lower fragment to project in front. The front of the capsule seems also thickened. In both specimens the cartilage covering the head is seen to be eroded as in arthritis deformans. G. C. 746. a. Presented % James Begbie, F.R.C.S.E., 1825. 3. 174. United Intra-capsular Fracture of the Neck.^ Anterior half of the upper end of a right femur — muscles cleaned off, and in spirit, showing the above. The line of fracture within the capsule is quite distinct.. There has been shortening and eversion, but not impaction. The cancellated tissue has been re-formed, except at the lower part of the neck, where the new bone is condensed. G. C. 2461. Presented by Wm. Sandees, F.KC.S.E. Fractures of the Femur. 107 3. 175. United Intra-capsular Fracture of the Neck.— Posterior half of the foregoing specimen — muscles cleaned off, and in spirit. This section shows points similar to those seen in the previous specimen. G. C. 2462. Presented by'W. Sanders, F.R.C.S.E. 3. 176. United Intra-capsular Fracture of the Neck.— Upper part of the right femur of an old man — macerated, and sawn transversely through the head and neck to show the internal structure. The patient was a man aged seventy. There is complete osseous union and restoration of the cancellous tissue, but with shortening and marked eversion. The specimen, which resembles the previous one, belonged to Mr John Lizars, and is referred to in his " Practical Surgery,' part i. p. 145. G. C. 3268. 3. 177. United Intra-capsular Fracture of the Neck of the Femur. — Plaster cast of the previous specimen, before section. G. C. 2781. Presented by Charles W. Cathcabt, F.R.C.S.E., 1888. 3. 178. United Intra-capsular Fracture of the Neck.— Sections of the upper end of the left femur of an old lady — macerated, and showing the above. The neck has given way within the capsule. The trochanter is higher than the head, and the neck is shortened. The lower fragment has been somewhat everted. The internal structure of the bone cannot be properly studied on account of the presence of adipocere. G. C. 2268. Presented by P. Newbigging, F.R.C.S.E. 108 Injuries of Bone. 3. 179. Ununited Intra-capsular Fracture of the Neck. — Upper end of the left femur of an adult — muscles dissected off and in spirit, showing the above. The upper fragment is irregular and unchanged. Some absorption has occurred at the broken margin of the lower fragment, and the capsular ligament is greatly thickened. F. P. C. 86. 3. 180. Ununited Intra-capsular Fracture of the Neck. — Anterior section of the upper end of the right femur of a woman, muscles dissected off — in spirit, showing the above. The patient lived for two months after the injury. The capsule is greatly thickened. The neck of the bone is absorbed, and the broken surfaces, which are covered by a soft material, fit into one another, the lower being slightly convex and the upper concave. A few ligamentous bands unite the broken margins in front. Figured in Bell's "Observations on Injuries of Spine and Thigh Bone," plate vii. fig. 3. B. C. I. 1. M. U. 3. 181. Ununited Intra-capsular Fracture of the Neck. — Upper end of a right femur, the muscles partly cleaned off — ■ in spirit, showing the above. The capsule is thickened ; the bone has been absorbed on the adjacent surfaces of both fragments, and ligamentous bands connect the margins of the fractured surfaces. G. C. 174. Presented by William Newbiggixg, Esq. 3. 182. Ununited Intra-capsular Fracture of the Neck.— Anterior half of the upper end of the left femur of an adult, muscles and ligaments cleaned off — in turpentine, showing the above. There has been absorption of the neck, and the broken Frachires of the Femur. 109 surfaces, which are alternately slightly concave and convex, are united by fibrous bands. Some new bone has been thrown out round the broken margin of the lower fragment, and a small nodule is seen at the top, attached by fibrous tissue. There is a slight amount of bony enlargement on the lower portion of the head, which constitutes the upper fragment. B. C. I. 1. M. 15. 3. 183. Ununited Intracapsular Fracture of the Neck.— Posterior half of the upper end of the left femur of an old man, muscles cleaned off — in spirit, showing the above. The case was considered by some surgeons to be one of unreduced dislocation of the femur. Sir Charles Bell in consultation confirmed the diagnosis of fracture of the neck of the femur, and this was afterwards verified hy post-mortem examination. The patient lived for two years after the accident. The capsule of the hip joint has been greatly thickened, and the neck of the bone has been almost entirely absorbed. Fibrous tissue unites the broken surfaces which are flattened. The cartilage covering the head of the bone shows the changes usually found in arthritis deformans. Figured in Bell's "Observations on Injuries of Spine and Thigh Bone," plate viii. fig. 1. B. C. I. 1. M. 19. 3. 184. Ununited Intra-capsular Fracture of the Neck.— Left half of the pelvis of an adult, with the head of the femur fixed in the acetabulum — macerated, to show the above. The portion of the femur remaining includes only part of the head, but possibly the bone was absorbed after the fracture. The exposed surface, somewhat irregular in outline, is for the most part smooth and condensed. Around the acetabulum new bone has been formed at one or two places. There are fissures on the ilium, but these may have been made post mortem. G. C. 1013. 110 Injuries of Bone. 3. 185. Somewhat recent Extra-capsular Fracture of the Neck, without splitting* of the Great Trochanter.— Upper end of a right femur — niacerated, showing the above. The specimen was taken from a subject in the dissecting-rooms. The patient had probably survived the injury for several weeks. The line of fracture is just within the capsule in front, but is outside of it behind. The lesser trochanter is wanting. New periosteal bony growth is seen on the front of the neck, especially on the lower fragment, and other evidences of periostitis can be traced for several inches down the shaft. Some absorption has taken place in the interior. The fracture has apparently been produced by a fall on the trochanter, with a force sufficient to detach the neck from the rest of the bone, and to break off the lesser trochanter, but not sufficient to split the greater trochanter by crushing it in upon the root of the neck. G. C. 2774. Presented by M 'Donald Browx, r.R.C.S.E. 3. 186. Somewhat recent Impacted Extra-capsular Frac- ture of the Neck. — Upper end of a right femur — macerated, showing the above. From the periosteal new bone thrown out at the upper end of the shaft of the femur, the patient has evidently survived the accident for several weeks. The neck has given way at its junction with the great trochanter, and the latter has been comminuted by the impaction of the neck into it. The locking of the neck into the fragments of the trochanter has been undone, probably in the preparation of the specimen. In the printed Catalogue published in 1836 this specimen was taken to be that numbered in the Bell Catalogue, i. 1. M. 18, and figured in Bell's "Observ. on the Spine and Thigh Bone," pi. viii. fig. 4. It does not however correspond to the descrip- tion of that specimen, and has been entered afresh in the G. C. as 3275. Fractures of the Femur. Ill 3. 187. Recent Impacted Extra-capsular Fracture of the Neck. — Upper end of a right femur — muscles cleaned off, and in spirit, showing the above. The patient, a man aged 70, fell from a bed a foot and a half high, and struck his hip. There was eversion, but no shortening. He died in six days at Montrose Infirmary. The neck has given way at its junction with the trochanters. The small and the posterior and upper part of the great trochanter have been split oflf from the shaft by impaction. A few tags of fibrous tissue still unite the neck to the upper part of the shaft and to the detached fragments. G. C. 1743. Presented by W. A. F. Browne, 1835. 3. 188. Recent Impacted Extra-capsular Fracture of the Neck. — Upper end of a left femur — muscles dissected off, and in spirit, showing the above. Some of the pieces are opened out at the back, to show the relations of the fragments. A pensioner, aged 80, when intoxicated, slipped and fell on the floor. "He violently refused to have the injury examined or any remedy applied," and died on the twelfth day after the fall. Unorganised lymph and decolourised blood-clot cover the broken surfaces of bone. The mode of comminution is similar to that seen in the previous specimens. G. C. 1300. Presented by Wm. Brown, F.R.C.S.E. 3. 189. Somewhat recent Impacted Extra-capsular Frac- ture of the Neck. — Upper end of the left femur of an adult, — muscles dissected off, and in spirit, showing the above. Some of the pieces are opened out at the back to show the relations of the fragments. The patient, who was under 50 years of age, was thrown violently to the ground, falling upon the point of the trochanter. He died of a chronic disease. The great and small trochanters are split in a way quite analogous to that seen in the previous specimen, except that the injury is more severe. 112 Injuries of Bone. The broken surfaces are covered with lymph, or forming fibrous tissue. The capsular ligament is considerably thickened. G. C. 1474. Presented by Alexander Simpson, F.R.C.S.E., 1832. 3. 190. Extra-capsular Impacted Fracture of the Neck, uniting". — Upper end of a left femur — macerated and varnished, showing the above. The patient lived for three months after the injury, and the toes were said to have been "inverted." Since, however, the linea aspera is in line with the head, this must have been a misprint for " everted." The neck has given way, as usual, at its junction with the trochanters, and these, in turn, have been detached from the shaft, and severely comminuted by the impaction. There has been no union, but new periosteal bone has been formed round the upper part of the shaft and on the fragments of the trochanters. The neck shows some erosion, but no new bone formation. G. C. 174. a. Presented hy Professor J. W. Turnee. 3. 191. United Extra-capsular Fracture of the Neck.— Upper end of a left femur — macerated and varnished, showing the above. The neck has given way at the usual place, and its anterior broken border is in front of the upper end of the shaft. The upper and back part of the great trochanter and the lesser trochanter have been detached in one piece from the top of the shaft. The axis of the neck is horizontal. There has been an unusually great shortening, but very little rotation either way. The greater part of the head and adjacent neck have been absorbed. It Avill be observed that while there is much new periosteal bone upon the tipper part of the shaft, there is much less upon Fractures of the Femur. 113 the detached fragment bearing the small and part of great trochanters, and little or none, only absorption, upon the head and neck. B. C. i. 1. M. 20. b. 3. 192. United Extra-capsular Fractupe of the Neck.— Upper end of a left femur — muscles dissected olf, in spirit, showing the above. A portion has been sawn out from the head and neck, to show the bony union. As in the previous specimen, the anterior part of the neck has been thrust in front of the upper part of the shaft. The great trochanter is splintered much in the usual vvay. There has been shortening and eversion. G. C. 3280. 3. 193. United Impacted Extra-capsular Fracture of the Neck. — Sections of a right femur — macerated, showing the above. The patient was a womaii aged 77. The fracture occurred in March 1886, when she was 71 years of age. She was successfully treated in Professor Chiene's ward, Koyal Infirmary, Edinburgh, and died in the Workhouse in April 1892. The bone shows the usual appearances produced by a slight amount of impaction of the neck upon the trochanters. The shortening and eversion must have been very slight. The cancellous tissue has been re-established, but at one or two places it was replaced by fat. G. C. 3383. Presented by G. M. Johnston, M.D. 3. 194. United Extra-capsular Fracture of the Neck.- Anterior half of the upper end of a right femur — macerated, with a plaster cast of the posterior half of the same specimen. Four years before death, the patient, an old lady aged 71, fell on the carpet in her room, and immediately afterwards sufi"ered from pain and powerlessness of her right limb. She was seen by Drs John Duncan and R. A. Lundie, who recognised "the usual symptoms of unimpacted extra-capsular fracture of the femur. It had none of the symptoms of H 114 Injuries of Bone. an impacted fracture." After six weeks of treatment by long splint and extension, the bone seemed united, but a starch bandage was applied and kept on for some time afterwards as an extra security. In a year or so she had as good use of her limb as she had had before. The bone shows the usual appearances produced by a slight amount of impaction of the neck upon the trochanters, i.e. some thickening at the front of the neck and some splitting at the back of the great trochanter. The eversion must have been very slight, and there seems to have been no shortening at all, possibly owing to the extension used in the treatment. Tlie anterior half shows that the cancellous tissue has been reformed with even less indication of fracture than in the previous specimen. G. C. 2905. Presented by R. A. Lundie, F.R.C.S.E. 3. 195. United Impacted Extra-capsular Fracture of the Neck. — Right femur of an old person — macerated, showing the above. The specimen was taken from a subject in the Dissecting Rooms. The neck has been impacted upon the trochanter, with the usual splitting, and has united. The union, however, has taken place in an unusually oblique position, so that the neck is almost in line with the shaft, and is raised well above the trochanter. The bone is exceedingly light and soft. G. C. 3333. Presented by Macdonald Brown, F.R.C.S.E. 3. 196. United Impacted Extra-capsular Fracture of the Neck. — Sections of the upper end of a left femur — macerated, showing the above. The patient, a man aged 40, fell from the top of a loaded carrier's cart on to the causeway. Drs D. Clarke and Abercromby diagnosed a, fracture of the neck of the femur from the sliortening, evenion, and crepitus, and sent him into Hospital, where he was treated with the double-inclined plane. The shortening and eversion remained, but he Fractures of the Femur. 115 was able to go about, wearing a high-heeled boot, and with the aid of a stick. Five years after the injury the man died of some pulmonary affection. The signs of impaction and splitting seen in the previous specimens are here well marked, and there has been consider- able shortening and eversion. The restoration of the cancel- lous tissue without indication of the line of fracture is quite complete. G. C. 722. Presented by Dr Clakke, 1824. 3. 197. United Impacted Extra-capsular Fracture of the Neck, with Chronic Ostitis of the Shaft.— Eight femur of an elderly person — macerated, showing the above. There has been much eversion and considerable shortening. The whole shaft of the bone is thickened and increased in weight. The great trochanter has been split by the impaction upon it of the neck, but there is nothing in the specimen to indicate whether the ostitis has followed the fracture or was there when the bone was broken. B. C. i. 1. M. 33. h. 3. 198. United Impacted Extra-capsular Fracture of the Neck. — Right femur of an old person — macerated, showing the above. The great trochanter has been split by the impaction of the neck upon it, as in the previous specimens. There has been marked shortening and eversion. The bone is very light, and there seems to have been a process of absorption going on in the head of the bone. F. P. C. 582. 3. 199. United Impacted Extra-capsular Fracture of the Neck. — Anterior half of the upper end of the right and posterior half of that of the left femur of an elderly person — • macerated, to show the effects of a healed fracture on the right side. 116 Injuries of Bone. The fractured specimen shows the impaction of the neck upon the trochanter. The neck has given way at the usual place, but its anterior broken margin, instead of, as in Nos. 3. 191 and 192, being forced in front of the corresponding margin of the lower fragment, has been forced behind it, so as to be •embedded in the upper end of the bone. These two modes of union thus each leave a ledge at the line of junction in front. It is more usual, however, to find an angle there — see Nos. 3. 193 to 198. The section of the bone shows the restoration of the cancellous tissue except at two points, above and below, where the bone is condensed. The tip of the trochanter is on a some- what higher level than that of the head. The section of the sound side shows a certain amount of absorption of the cancellous tissue due to old age, but the angle of the neck seems in no way altered. G. C. 3662. Presented by H. Alexis Thomson, F.R.C.S.E., 1892. 3. 200. United Impacted Extra-capsular Fracture of the Neck.— Upper end of a right femur — macerated, showing the above. A section has been made of the head and neck to show the interior of the bone. The neck has given way, as is usual in this fracture, at its junction with the shaft. The small trochanter has been split off. The tip of the great trochanter is above the level of the head, and the linea aspera is directed inwards, hence there must have been marked shortening and eversion. The head of the bone shows changes like those produced by arthritis deformans, a disease which often attacks injured joints in old people. The bony union is complete. As in the previous specimen, the upper fragment has been forced behind the lower, leaving a similar ledge shelving backwards from the lower fragment to the upper. This specimen is figured in Bell's "Observations on Injuries of Spine and Thigh Bone," plate vii. fig. 2. B. C. I. 1. 20. a. Fractures of the Feimir. 117 3. 201. Ununited Extra-capsular Fracture of the Neck.— Upper end of a left femur — macerated, showing the above. The neck of the bone has apparently given way nearer to the head than usual, but there has been the characteristic splitting of the great trochanter by impaction of the neck into it. Much new bone has been thrown out from the upper part of the shaft behind, below, and especially in front. The majority of the smaller fragments have united to one another and to the main piece only by fibrous tissue. The upper fragment, consisting of the head and part of the neck, has no new bone formed upon it, and its broken margin is quite sharp, except where it has been mechanically worn against the upper part of the shaft. Above this worn part the surface of the bone shows some superficial erosions, as if granulation tissue had been absorbing it. The want of formative power in this upper fragment is probably due to insufficient vascular supply, a condition which so often leads to non-union in the intra- capsular variety of fracture. See N"o. 3. 179. G. C. 098. 3. 202. Ununited Extra-capsular Fracture of the Neck.— Upper end of a left femur — muscles cleaned oflF, in spirit, showing the above. The patient survived the injury several yoars. During the patient's life there was difference of opinion among several surgeons as to the exact nature of the injury. The case was originally treated as one of fracture of the neck, but some afterwards held that it was an unreduced dislocation. Sir Charles Bell in consultation confirmed the diagnosis of fracture, and this view was verified at the post-mortem examination. The fracture has the usual characters as to the giving way of the neck and splitting of the trochanters. The fragments are united by firm fibrous tissue, and the leg has been considerably shortened and everted. B. C. i. 1. M. 20. 3.203. Ununited Impacted Extra-capsular Fracture of the Neck, with great Displacement. — Last three lumbar 118 Injuries of Bone. vertebrse, pelvis, and femora — macerated, showing the above. The bones on the fractured side are placed in the position in which they were found on dissection. The fracture is of the impacted extra-capsular variety. It will be seen that the great trochanter has been split, and that one of the fragments, along with the shaft of the bone, has been drawn up to the crest of the ilium. The head and neck remain in their normal position. B. C. i. 1. M. 17. 3. 204. Ununited Impacted Extracapsular Fracture of the Neck, with great Displacement. — Plaster of Paris cast of a left innominate bone, and the upper end of the corresponding femur, showing the above. As in the last specimen, the great trochanter has been drawn up to the crest of the ilium. The connection between the upper end of the shaft and the ilium was not composed of bone, as it seems to be in the cast. The appearance of bony union is due to a fault in the cast. Copied by permission from a specimen in Dr Joseph Bell's collection. G. C. 3088. Presented hy Charles W. Cathcart, F.R.C.S.E. 3. 205. United Extra-capsular Fracture and Ununited Intra-capsular Fracture of the Neck, with Arthritis Deformans. — Upper end of a right femur — macerated, show- ing the above. The appearances presented by this specimen are remarkable and unusual. The lower fragment at its upper end has all the appearance of a healed impacted extra-capsular fracture, of the type seen in Nos. 3.199 and 3.200, to the latter of which it has a considerable resemblance. But there is also an ununited fracture of the neck, as well as changes in the upper fragment, such as are produced by arthritis deformans. It is highly probable that arthritis deformans followed the impacted extra- Fractures of the Femur. 119 ■capsular fracture, and that, last of all, the neck was broken close to the head. The adjacent surfaces of both fragments are very irregular, but have been rounded off by vital processes. This specimen is figured in Bell's "Observations on Injuries of the Spine and Thigh Bone," plate viii. fig. 3. B. C. I. 1. M. 16. 3. 206. United Oblique Fracture above the Small Troch- anter.— Upper end of the shaft of a right femur, with a section through the head and neck, to illustrate the above — macerated. The specimen was taken from a subject in the Dissecting Rooms. The head, neck, and great trochanter have been split off from the small trochanter and shaft. The upper fragment has been tilted outwards, but not forwards. This displacement is probably dependent upon the direction of the obliquity of the fracture, which has run from within outwards and downwards, leaving the psoas and iliacus muscles upon the lower fragment. The spaces seen in the interior of the bone were filled by a brown, jelly-like material. Bony union has been complete. G. C. 3255. Presented hj Johnson Symington, F.R.C.S.E. S. 207. United Oblique Fracture above the Small Tro- chanter.— Upper end of a right femur, head and neck wanting — macerated, to illustrate the above. The line of fracture has begun at the back, about one inch above the small trochanter, and has thence passed obliquely downwards and forwards for three or four inches. In this specimen also the direction of the obliquity has apparently determined the displacement. The head, neck, and great trochanter have been obliquely split off from the shaft and small trochanter. The upper fragment is tilted forwards, and the two over-ride. G. C. 2276. 120 Injuries of Bone, 3. 208. Comminuted Fracture of the Upper End of the Shaft and Great Trochanter.— Upper end of a right femur — macerated, showing the above. A portion of the head has been sawn off, for convenience in mounting. The patient was a coachman. " He was in the act of pulling up his horses, when the foot-board broke, and he was precipitated, with his weight falling in the line of the thigh-bone. The urethra was burst." He lived for six weeks all but two days. The head, neck, and front portion of the upper end of the shaft form one fragment, which projects forwards. The trochanters, and a splinter of about four inches of the back of the shaft, form another fragment, which in its turn is some- what comminuted above, while the remainder of the shaft forms the lower fragment. Much new bone has been formed from the upper end of the shaft, some from the trochanteric fragment, and only a very- little from the head and neck fragment. This specimen is figured in Bell's "Observations on Injuries of the- Spine and Thigh Bone," plate vii. fig. 1. B. C. I. 1. M. 20. c. 3. 209. United Fracture below the Small Trochanter.— Plaster of Paris cast of the upper end of a right femur in the Barclay Collection, showing the above. There had been firm, osseous union. The upper fragment has been tilted much forwards. The lower fragment has been- drawn up, but neither fragment has been rotated. G. C. 3281. 3. 210. structure of the Shaft of the Femur. — Longitudinal section of a right femur — macerated, to illustrate the above. The specimen shows the relative proportion of cancellous and compact tissue in the shaft and at the extremities. G. C. 3559. Fractures of the Femur. 121 3. 211. Recent Fracture at the Lower End of the Shaft.— Lower end of a right femur — macerated, showing the above. The line of fracture is irregularly transverse, and there has been some comminution at the inner side. The periosteum indicates some previous inflammation. The compact tissue of the shaft is extremely dense, and is increased in thickness at the expense of the medullary cavity. The weight of the bone is abnormally great. G. C. 762. MODE OF UNION IN FEACTUEES OF THE SHAFT. 3. 212. Recent Oblique Fracture of the Shaft in a previously Diseased Femur.— Right femur — macerated, showing the above. The fracture has occurred at the junction of the middle and lower thirds, and is somewhat spirally oblique from behind downwards and forwards. The edges are sharp, as if sufficient time had not elapsed for union. The whole shaft is irregularly thickened, as by syphilitic nodes, and the lower articular surface has been altered in a manner similar to that seen in tubercular disease with spontaneous cure. Remark. — "When the thigh-bone is fractured by a person dropping from a height it is in general fractured obliquely, as in the present instance ; and the extremities of the bones are thrust past each other, both in consequence of the direction of the force, and from the points penetrating easily into the flesh." (Sir Charles Bell's M.S. Catalogue.) B. C. i. 1. M. 10. 3.213. Comparatively Recent Oblique Fracture of the Shaft. — Section of the shaft of a femur, near the lower end — injected and in spirit. " The young man was seized with erysipelas, which carried him off. This affords us an opportunity of observing the progress of re-union." The interval between the broken ends of the bone is occupied by soft material, an early stage of fibrous tissue, which would have eventually developed into bone. B. C. 1. 1. M. 42. 122 Injuries of Bone. 3. 214. Comparatively Recent Oblique Fracture of the Shaft. — Section of the shaft of a femur — muscles dissected off — dried, injected, and in turpentine, to illustrate the above. Time was not afforded for union by bone. The specimen shows the vascularity of the material covering the broken surfaces, and from which the new bone would have been formed, B. C. i. 1. M. 44. 3.215. Comparatively Recent Oblique Fracture of the Shaft. — Section of the lower end of a right femur — muscles cleaned off, and in spirit, showing the above. The lower fragment over-rides in front of the upper, and the ends overlap for about four inches. The interval between the broken ends of the bone is filled up by soft, fibrous-looking material, which would have eventually developed into bone. G. C. 2068. Presenicd hy P. Newbigging, F.R.C.S.E., 1840. 3. 216. Comparatively Recent Comminuted Fracture of the Shaft. — Portion of the shaft of a femur — macerated, showing the above. " The person lived some days after the accident, and at the time of his death was a patient in the Middlesex Hospital, from the house- surgeon of which, Mr Le Mann, I received the preparation. The fracture seems to have proceeded nearly half through the bone from before, with- out detaching but one large piece ; more backward several splinters have broken off, many of which have united to a different part of the bone than that which they were detaclied from. One part in particular shows this, from the direction of the external fibres being ver}' oblique in the splinter, and running directly from above downwards in the part of the bone from which it was broken off. A piece of bone from three to four inches in length on the back part of the femur, but not reaching the anterior surface of it, has been broken off, and, without change of position, has united in some places to the bone above, and had began to unite with the bone below. Splinters of bone are found adhering even to the detached portion. In some places there seems to have been no attempt at union. Fractures of the Femur. 123 This . . . demonstrates that splinters in fracture are sometimes broken off, and again adhere even to other surfaces than those from which they were broken, and that splinters do not necessarily lose their principle of life." W. C. G. 4. 3. 217. United Fracture of the Shaft.— Lower portion of the shaft of a femur — macerated. A section is removed from the fractured portion, to more clearly illustrate the mode of union. The section shows that the ends of the medullary cavity have been closed by a thin plate of bone, and that the interval between the broken ends is occupied by cancellous tissue, which has a thin, compact plate on the outside continuous with the adjacent surfaces of each fragment of the shaft. The upper fragment over-rides in front of the lower, and is set at an angle to it. B. C i. 1. M. 32. c. 3. 218. Somewhat recent Compound Fracture of the Shaft. — Portion of the shaft of a femur — muscles removed, to illus- trate the above — in spirit. From a patient 65 years 'of age, in the Royal Infirmary, wlio received a compound fracture near the middle of the bone. Several of his ribs were also broken, and he suffered considerably from inflammation of his lungs. He was affected with jaundice, and erysipelas of the injured leg came on five days after the injury. Extensive abscesses took place, his pulse intermitted, his limbs became cedematous, diarrhoea came on, and he died six weeks after the injury. The broken extremities of the bone seem to be dead, but have not had time to become loose. There has been no attempt at union. G. C. 2225. Presented by Alexander Watson, Esq. , 1839. 3.219. Comparatively recent Compound Fracture of the Shaft. — Lower end of a left femur — macerated, showing the changes dependent upon the above. 1 24 Injuries of Bone. 3. 219. (Contd.) — The fracture has been nearly transverse. A part of the bone at the seat of fracture has necrosed, and has been in process of separation. Beyond the commencing groove ©•f separation, irregular, newly-formed bone has been thrown out. The fracture has probably been compound and septic. F. P. C. 125. 3. 220. United Compound Fracture of the Shaft.— Eight femur of a young person — macerated, showing the above. Alii the epiphyses, except that for the small trochanter, have been lost during maceration. The lower fragment is internal to the upper, and it& lower end has been tilted forwards and outwards. There ha& been much inflammation, and the surfaces above and below the fracture are crusted with newly-formed periosteal bone.. The fracture has therefore probably been comppund. F. P. C. 126. 3. 221. Badly united Fracture a little way below the Small Trochanter. — Upper end of a left femur — macerated,, and divided vertically, showing the above. The line of fracture has begun below the small trochanter,. and has run obliquely downwards and outwards. The upper fragment is tilted outwards, and over-riding has occurred. The medullary cavity is interrupted by cancellous tissue. The union has been very solid. F. P. C. 105. 3. 222. United Fracture a little below the Lesser Tro- chanter.— Left femur — macerated, showing the above. The upper end is tilted outwards and slightly forwards.. The lower part of the shaft has lost its usual forward bend,, and has received a slight bend backwards as well as one distinctly outwards. The outer condyle is thus relatively raised, and some knock-knee must have existed. Although in some respects the shape of this bone resembles that found in rickets, its similarity to the specimens which pre- Fractures of the Femur. 125 cede and follow it renders more probable the theory of old- standing fracture. The lower part of the shaft shows signs of a slight perios- titis. B. C. I. 1. M. 32. a. 3. 223. United Fracture a little below the Lesser Tro- chanter.— Left femur of an aged man— macerated, showing the above. The upper fragment has been tilted outwards and slightly forwards, and the level of the head is below that of the great trochanter. There is much thickening round the fracture, extending downwards in the shaft. The broken ends have been hidden in front by the callus, but are still distinct behind. The lower end of the shaft preserves its normal forward bend, but, as in the former case, the inner condyle is prolonged downwards, and there has probably been knock-knee. The whole bone is lightened, probably, however, from advanced age. The articular surfaces show changes indicative of arthritis deformans. B. C. I. 1. M. 32. b. 3. 224. Badly united Fracture a little below the Lesser Trochanter. — Right femur of an adult — macerated, showing the above. The upper fragment is tilted greatly outwards, and is displaced behind the lower one. The head of the bone is on a level with the great trochanter, and the whole shaft has had an outward bend at the seat of fracture, which is only partially compensated for by a slight bend inwards at the lower end. The inner condyle i§ prolonged downwards, and there has evidently been knock-knee. The bone, although not thickened, is unusually heavy. From the roiihding off of the prominences at the seat of fracture, and from the evidently secondary changes in the lower end of the shaft, the fracture may be considered one of long standing. B. C. i. 1. M. 28. 126 Injuries of Bone. 3, 225. Badly united Fracture a little below the Lesser Trochanter. — Plaster cast of the pelvis and thighs of the patient from whom the previous specimen was taken. The cast shows the distortion of the injured thigh, con- sequent upon the irregular union of the fractured femur. B. C. I. 1. M. 32. 3. 226. Badly united Fracture through the Upper Third of the Shaft. — Inner section of the upper end of a right femur — macerated, showing the above. The head is wanting. There has been a fracture about three inches below the lesser trochanter, and the upper fragment has over-ridden in front of the lower. The ends of the bones have been encased in an irregular mass of cancellous tissue, which has also interrupted the medullary cavity. The upper fragment is tilted forwards and slightly outwards. B. C. i. 1. M. 33, i. 3. 227. United Fracture at the Junction of the Upper and Middle Thirds. — Left femur of a strong man — macerated, showing the above. The upper fragment is tilted slightly forwards, but the union is otherwise good. There is not much callus at the seat of fracture, yet the whole bone is heavier than it should be. The difiference between the weight of the bone in this and in Xo. 3. 223 may have been due to the difference in age of the individuals. This specimen has probably been taken from a middle-aged, the other from an old person. B. C. i. 1. M. 27. 3. 228. United Fracture about the Middle of the Shaft.— Inner half of the central portion of the shaft of a left femur — macerated, showing the above. The upper fragment has been tilted forwards, and a large Fractures of the Femur. 127 amount of dense new bone has been thrown out round the seat of fracture. On the surface of the callus there are numerous apertures for the entrance of blood-vessels. B. C. I. 1. M. 33. e. 3. 229. Badly united Fracture about the Middle of the Shaft. — Left femur — macerated, showing the above. The upper fragment has been tilted'forwards and inwards ; the lower end is rotated slightly outwards. The broken ends over-ride, and are separated by a considerable interval which is filled up by dense new bone formation. The broken ends of the bone must at one time have exposed the medullary cavity, but this is now covered in by new bone. Figured in Bell's "Observ. on Injuries of Spine and Thigh Bone," plate vi. fig. 3. B. C. I. 1. M. 26. 3. 230. Double Fracture of the Shaft united in Bad Posi- tion.— Shaft and upper end of the left femur of an adult — macerated, to show the above. This was the thigh-bone of a madman, who threw himself out of the window, and kicked and struggled so that they could by no means secure the position of the limb. The thigh-bone iu its natural state was 18 inches in length ; it is now only 13 inches. It lost 5 inches in length, yet to that diminution had the muscles adapted themselves. There has been over-riding at both fractiires, and great distortion at the upper one. The medullary cavity has been partially covered in, and the uniting bone at both fractures is stiU cancellous. Figured in Bell's "Observ. on Injuries of Spine and Thigh Bone," plate vi. fig. 6. B. C. I. 1. M. 23. 3. 231. Unitec^ Fracture about the Middle of the Shaft. 128 Injur its of Bone. 3. 231. {Co7itd.) — Upper end of a right femur — macerated — with section through the seat of fracture, to show the above. The upper fragment has been tilted forwards, and over- rides the lower one. A longitudinal splinter seems to have been broken from the inner side of the shaft. The medullary- cavity has been closed in by bone, and the broken ends have been united by bone, which in some places is extremely dense. W. C. G. 7. 3. 232. United Fracture about the Middle of the Shaft. — Left femur — macerated, showing the above. The upper fragment over-laps behind the lower one, which is rotated outwards. The broken ends of the bone have been united by a dense callus, and the exposed medullary cavity has been closed in in each fragment. It should be noted that in fractures at this level the upper fragment is usually displaced in front of, not behind, the lower one. B. C. i. 1. M. 30. 3. 233. United Fracture at the Middle.— Left femur- macerated, showing the above. The upper fragment over-rides in front of the lower, and both are tilted outwards. There is considerable callus between the broken ends. The closing of the medullary cavity of the broken ends, and the smoothing over of the strong intervening callus, are similar to that seen in previous specimens. B. C. I. 1. M. 33. c. 3. 234. United Fracture about the Middle of the Shaft. — Right femur — macerated, showing the above. The upper fragment is tilted forwards and over-rides in front of the lower. The medullary cavity is closed in, and the callus between the fractured ends is just sufficient to unite them. Fractures of the Femur. 129 It may be observed in this, as in many of the previous speci- mens, that no callous formation has at least been permanent, except between the broken surfaces of the bone, where it is of service in uniting them. G. C. 363. 3. 235. United Fracture about the Middle of the Shaft. — Posterior section of lower end of a left femur — macerated, showing the above. The upper fragment has lain in front of the lower, and the broken ends have been drawn inwards. The union has evidently been of long standing. B. C. i. 1. M. 33. f. 3. 236. Badly united Fracture about the Middle of the Shaft. — Right femur — macerated, showing the above. The upper fragment is in front of the lower. They both over-ride to a considerable extent, and at their junction form an obtuse angle, pointing inwards. The lower fragment is rotated outwards through an angle of about 45°. The medullary cavity is closed in, and the ends are united by an irregular mass of bone. F. P. C. 123. Presented hy Professor John Thomson. 3. 237. Badly united Fracture about the Middle of the Shaft. — Fragment of the shaft of a femur — macerated, showing the above. The specimen was found in the bush, among other bones, at Sangaga, Vintang Creek, south bank of the Gambia, W. Africa, on 13th January 1891. There was evidence of a fight having occurred at the spot some time before. The upper fragment is anterior and internal to the lower, and a firm mass of bone unites them. G. C. 3457. Presented hy J. Lester, M.B., CM. I 130 Injuries of Bone. 3. 238. Badly united Fracture about the Middle of the Shaft. — Right femur — macerated, showing the above. The upper fragment, sharply pointed, over-rides in front of the lower, and at a distance from it of about 1| inches, and yet the interval is partly filled up by dense callus. The lower fragment is tilted outwards below, and is rotated, slightly out- wards. Figured in Bell's "Observations on Injuries of Spine and Thigli Bone," pi. vi. fig. 2. B. C. I. 1. M. 25. 3. 239. Badly united Fracture, a little below the Middle of the Shaft. — Right femur — macerated, showing the above. The upper fragment over-rides in front of the lower, and at a distance from it of about \^ inches, and yet the interval is- completely filled up by dense callus. The medullary cavity of each fragment has been closed over, and, as in many of the previous specimens, the callus has a smooth outer shell, con- tinuous with the adjacent portions of the shaft. The fragments are in line, and the lower one is rotated slightly outAvards. B. C. I. 1. M. 33. k. 3. 240. Badly united Fracture at the Junction of the Middle and Lower Thirds of the Shaft.— Left femur — macerated, showing the above. The bones are united in a manner similar to that seen in the foregoing specimen, but with less interval between the fractured ends. The upper fragment is in front of the lower. Above the seat of fracture it is curved outwards and forwards, and its diameter, increased in the direction of the curve, is flattened from side to side. The lower fragment is rotated, outwards, but is very little changed in appearance. B. C. I. 1. M. 33. d. Fractures of the Femur. 131 3. 241. Badly united Fracture in the Lower Third of the Shaft. — Right femur — macerated, showing the above. The upper fragment is in front and to the inner side of the lower, which is rotated very slightly outwards. The broken ends overlap considerably, and there is a large mass of callus between them. B. C. i. 1. M. 29. 3. 242. Ununited Fracture of the Shaft.— Portions of the shaft of a femur — with the muscles dissected off and in spirit, to show the above. "The bone was twice broken. After the first accident, matters- seeming to go on prosperously, he had risen from bed, and was walking upon crutches, when his crutch slipped from under him, and he broke the bone a second time. It seemed now to be very ill set, for the preparation shows the bone riding, accordingly union by bone did not take place. A joint formed instead, and in this condition he was broughtinto the Middlesex Hospital. I made various attempts, by exciting the extremities of the bone, to produce what has been termed ossific inflammation, but without succeeding. At last, at the earnest request of the patient, the limb was amputated." The bones have been in bad position, greatly overlapping, and are now united by apparently fully-formed fibrous tissue. The medullary cavity of each fragment has been closed in by bone, and a spur of bone has grown from the side of the upper fragment. Between this and the lower fragment a false joint (adventitious bursa) has formed. This has been laid open, and a fibrous band crossing it is indicated by a bristle. The closure of the medullary cavity would indicate that the non- union in this case was at least not due to deficient power to form bone. B. C. i. 1. M. 11. 3. 243. Fracture of the Shaft, followed hy Sarcoma.— Section of a femur, soft parts dissected off — in spirit, showing the above. The patient, a man aged 45, fell and broke his femur. After it had united, he fell and broke the bone a second time. It was treated as before, 132 Injuries of Bone. and at the end of the usual time had united. Shortly afterwards a tumour arose in the centre of the thigh, and increased rapidly, with much pain. The thigh was amputated at the level of the small trochanter, but the patientdied. (See case of Phineas, Bell's "Surgical Observations," p. 376.) The specimen shows that the union between the broken ends has been complete, although the bones have overlapped. The masses of greyish tumour substance are seen invading the texture of the bone on both its inner and outer aspects. B. C. I. 1. M. 33. a. FEACTURES INVOLYIXG THE KNEE-JOINT. 3. 244. Double Fracture of the Condyles— Lower ends of the right and left femur of a young man — macerated, showing the above. The patient threw himself over a window four storeys high, in con- sequence of a melancholy state of mind There was concussion, with effusion of blood on the brain, and abscess of the liver, which had burst into the thorax through the diaphragm. He lived only two hours after the fall. On the left side the outer condyle has been split into two pieces. On the right side the condjdes and the bone in their immediate neighbourhood have been severely comminuted. G. C. 1738. Presented by Professor J. W. Turner and A. Watsox, Esq. 3. 245. Splitting" of the Condyles, with Fracture of the Shaft. — Portions of the lower end of a left femur — macerated, showing the above. The patient, a young French sailor, fell on the deck from the mast-head of a ship in Leith Roads, and sustained, besides this comminuted and compound fracture of the left femur, a simple fracture of the right femur, as well as a fracture of the lower jaw, and one of the base of the skull. He lived for twenty-four hours after the injury. The vertical split has separated the condyles as nearly as possible in the mesial plane. The transverse break has been Fractures of the Femur. 133 irregular, and has left more of the bone above the outer than above the inner condyle. G. C. 2475. Presented by W. A. Finlay, F.R.C.S.E., 1876. 3. 246. Compound Comminuted Fracture of the Lower Ends of the Condyles. — Lower end of the right femur of an old woman — macerated, showing the above. The knee was crushed between a cart-wheel and a wall. The patient was about 60 years of age, and lived six weeks after the accident, when she died from diseased aorta producing hydro-thorax. The condylar portion of the bone has been broken oflf from the shaft, and an oblique fissure has separated the inner and a small piece of the outer condyle from the rest of the condylar fragment. There has been an extensive formation of new periosteal bone upon the lower end of the shaft, but only a slight amount upon the lower fragments. The appearance of this new periosteal bone indicates septic irritation. It is probable, therefore, that the fracture has been compound. F. P. C. 137. Presented by Professor J. W. Turner and A. Watson, Esq. 3. 247. Fracture through the Condyles, followed by Sar- coma.— Inner half of the bones forming the right knee-joint — muscles dissected oflf, in spirit, showing the above. The fracture has been oblique from behind downwards and forwards. The lower end of the upper fragment has protruded into the front of the knee-joint. Between the fragments soft material is seen which in some places is fibrous, and in others is "fungus hsematodes" (sarcoma). B. C. I. 1. M. 33. b. 3. 248. Separation of the Lower Epiphysis of the Femur, 134 Injuries of Bone. — Right femur of a boy aged 13 — macerated, showing the above. The lower epiphysis is quite separate from the shaft. The patient fell from the joisting of a house on the floor below, and his right leg went through the flooring. When brought into the Hospital, the house surgeon reported to Mr J. a case of common fracture of the thigh-bone. He lay with the usual securities upon the limb for about a fortnight before I was called to consult upon it. The boy was hectic, much reduced, a dry tongue, irritable pulse, and upon the inside of the knee there were deep sloughy spots. Next day, in consec[uence of the restlessness of the boy during the night, I found the bone sticking through the integuments, and saw from the appearance of the bone that the case had been mistaken, and that, instead of a fracture communicating with the joint, it was a diastasis, or separation of the epiphysis. Even now I thought it not too late to amputate, with some chance of the boy's surviving, but it was thought he had somewhat rallied from the day preceding, and that he might lie still better on the morrow. On that day he died. The dissection exhibited great suppuration within the knee- joint, an immense abscess or cavity communicating with the knee-joint, and extending up the bone nearly to the hip. The periosteum could be torn with the fingers from half the length of the bone. Such, then, are the consequence of a diastasis of the lower head of the femur, and by this we see that the case classes itself with the worst kinds of fractures communicating with the knee-joint. Apparently a small portion has been broken off the lower end of the shaft. The surface of the shaft at the lower end has at some places a considerable crust of new periosteal bone, while at others the vascular pores are opened out. A similar opening out is seen all the way up the shaft. At the front of the neck a patch of the surface is eroded. These changes have evidently been due to septic osteo-myelitis, an accidental consequent of the injury. B. C. i. 1. M. 8. a. 3. 249. Separation of the Epiphysis, with Mal-union.— Lower end of a left femur — macerated, showing the above. A lad, in attempting to get upon the back of a gentleman's carriage, got his legs entangled within tlie spokes of the wheel, and the lower extremity of the femur was broken oft', suffering that sort of accident which was called diastasis. Union took place after this accident, but the broken portions united irregularly, and a i)oint projected. Years after this accident, and when the patient had grown into manhood, he sufi'ered an accident of a still more serious nature. In carrying a burden Fractures of the Patella. 135 on his head, his foot slipped, and in the attempt to recover himself the actions of the muscles of the thigh pressed the popliteal artery against the projecting point of bone, and the artery -was ruptured, and an aneurism was formed. It was found necessary finally to amputate the limb. (For the remainder of the case, see the series illustrating arterial disease.) Tlie epiphysis has been united to the lower end of the shaft, with its back part projecting downwards, and its inferior parts looking forwards. The lower end of the shaft projects behind the epiphysis, and is rough and irregular. Although the epiphysis and the shaft are in bad position, the union between them has been exceedingly solid. (Figured in Bell's "Observations on Injuries of the Spine and Thigh-Bone," plate iv. fig. 3.) B. C. i. 1. M. 9. FKACTUKES OF THE PATELLA, 3* 250. United Transverse Fracture of the Patella.— Patella — macerated, showing the above. There has been a longitudinal break on the inner side, and another extending transversely from the middle of the first. 'So new bone has been formed on the joint surface, and only a little on the outer surface. This fracture has probably been caused by direct violence. (See Bell's " Observations on Injuries of the Spine and Thigh Bone," p. 57, also plate iv. fig. 1.) B. C. I. 1. M. 61. 3. 251. United Irregular Fracture of the Patella.— Patella — macerated, showing the above. There is a deep longitudinal fissure on the articular surface, and considerable irregularity on the anterior surface. This has probably been a fracture by direct violence. B. C. I. 1. M. 62. 3. 252. Ununited Transverse Fracture of the Patella.— Patella — muscles cleaned off and in spirit, showing the above. 136 Inji tries of Bone. The ends are united by firm fibrous tissue, and are about a quarter of an inch apart. B. C. i. 1. M. 59. 3. 253. Ununited Transverse Fracture of the Patella.— Patella — muscles cleaned ofi" and in turpentine, showing the above. The ends of the bone, which are about half an inch apart, are united by fibrous tissue. B. C. i. 1. M. 58. 3. 254. Ununited Transverse Fracture of the Patella. — Patella — muscles cleaned off and in turpentine, showing the above. The ends of the bone, which are about one and a half inches apart, are connected by fibrous tissue. B. C. I. 1. M. 57. 3. 255. Ununited Transverse Fracture of the Patella.— Patella — muscles dissected off, in turpentine, showing the above. The ends of the bone are about one and a half inches apart ; on one side a piece of bone is embedded in the fibrous tissue- uniting the bone. B. C. i. 1. M. 56. 3. 256. Ununited Transverse Fracture of the Patella.— Patella — muscles dissected off and in turpentine, showing the above. The ends of the bone are about five inches apart, and thus very long fibrous union has taken place. In the fibrous tissue small calcareous particles are seen. W. C. G. 10. Fractures of the Patella. 137 ^. 257. Ununited Fracture of the Patella— Fibrous Union torn across. — Knee-joint — in spirit, showing the above. "The patella had been fractured, and ligamentous substance had formed betwixt the fractured portions, as in several specimens, and the muscles, adapting themselves to the lengthened tendons. The man could walk, but, walking under a heavy burden, he fell, and his leg bent under him, so that the new ligament was torn up, and the integuments which had united with it, and by consolidating had lost their elasticity, were torn also, so that, as is seen here, the interior of the joint was disclosed. The inflammation did not rise in the manner or to the extent I have seen take place from the puncture of the capsular ligament. Was this owing to there being disease previously ? " From the thinning and irregularity of the margins of the skin "svound, there seems to have been considerable suppuration after the accident. B. C. i. 1. M. 63. 3. 258. Ununited Fracture of the Patella. — Plaster cast of a right knee-joint, showing the above. The ends of the bone were about two inches apart. F. P. C. 2940. 3. 259. Fracture of the Patella. — Plaster cast of left knee- joint. The patient had evidently suffered from fracture of the patella, with a very wide separation of the fragments. G. C. 3314. FRACTURES OF THE TIBIA AND PROCESS OF UNION. 3. 260. Normal Tibia. — Section of a normal tibia — macerated. The specimen is mounted for comparison with the follow- ing fractured tibise. G. C. 3560. 3. 261. Recent Fracture of the Tibia, involving- the Knee-joint. — Upper end of a right tibia and lower end of 138 Injuries of Bone. the femur — injected and in spirit. The soft parts are cleaned off. There is an oblique fracture extending from before back- Avards through the upper part of the shaft of the tibia, and a split has extended upwards through the outer tuberosity into the articular surface. The knee-joint shoAvs signs of an early stage of arthritis deformans. F. P. C. 2966. 3. 262. Comminuted and Impacted Fracture of the Tibia, involving- the Knee-joint — comparatively recent. — Upper end of a right tibia and fibula — macerated, showing the above, which resembles the previous specimen. The patient died of erysipelas six weeks after the accident. The outer tuberosity has apparently been forced down- wards, and has been partly detached from the rest of the bone. The shaft has given way obliquely from without downwards and inwards at the level of the tubercle. The lower fragment has evidently been forced upAvards, for several pieces of bone are embedded in the upper fragment behind, while on the outer side of both fragments small pieces of bone have been everted. These injuries seem as if they might have been produced either by a fall on to the foot with the leg extended and the main pressure directed upon the outer side of the knee-joint, or by a severe Avrench tending to bend the knee-joint iuAvards, i.e. as if to produce knock-knee. G. C. 175. Frcsented by Professor JoHX Turner. 3. 263. Recent Comminuted Fracture of the Tibia and Fibula. — LoAver portions of a left tibia and fibula — macerated, shoAving the above, Avith the fragments Avired together. "The injury was compound. The knee-joint was in this case pre- served to the patient, although the fracture iiivoh'ed nearly the whole of the tibia ; indeed, the fibula was entirely removed." The bones have been severely comminuted. G. C. 1129. Presented by James Pitcairn, F.R.C.S.E. Fractures of the Tibia. 139 3.264. Comminuted Fracture of the Tibia and Fracture of the Fibula. — Lower two-thirds of a left tibia and fibula — macerated, showing the above, with the fragments wired together. The fracture was compound. The tibia is fissured and splintered irregularly, and the fibula broken, leaving a sharp lower fragment. G. C. 175. a. 3, 265. Fracture of the Tibia.— Upper end of a left tibia- macerated, showing the above. The fracture was a compound one, and the leg was amputated immediately after the accident. The shaft has been irregularly fractured in its lower third. There is a sharp point on the inner side which might have tended to pierce the skin. G. C. 1226. Presented by John Campbell, F.R.C.S.E. 3.266. Fracture of the Tibia. — Portions of a tibia — macerated, showing the above. The leg had to be amputated three weeks after the accident. The patient died. G. C. 1146. Presented by Professor James Russell, 3. 267. Somewhat recent Comminuted Fracture of the Shaft of the Tibia and Fracture of the Fibula.— Lower ends of a right tibia and fibula — injected, muscles cleaned off, and in spirit, to show the above. The injury was at first simple, but the leg became gangrenous, and, at the end of the third week, was amputated. The periosteum is thickened, and the broken surfaces are 140 Injuries of Bone. for the most part covered with lymph. At some places the compact tissue at the seat of fracture is smooth and bare. G. C. 312. Presented by Dr Maclagan and J. W. Turner, F.R.C.S.E. 3. 268. Uniting" badly-set Fracture of the Tibia and Fibula. — Portions of the shafts of the tibia and fibula, with the muscles dissected off — in spirit, showing the above. The upper fragment of the tibia is uniting to the lower fragment of the fibula, and the other fragments of each bone are free. The medullary cavities, where exposed, have been covered in, apparently as yet by soft material. The opposed fragments of the tibia and fibula have, however, been united by spongy bone, a slight crust of which is also seen on the adjacent tibia. G. C. 1053. Presented by Professor James Russell. 3. 269. United Fracture of the Tibia and Fibula.— Lower half of a right tibia and fibula. The limb was injected, the bone cleaned, and put into weak acid, then dried and placed in turpentine. The fibula, near the lower end, has an indistinct fissure, and shows considerable enlargement and bony growth on the surface, as if this part had lain beneath an ulcer. The tibia has been irregularly broken about four inches above the ankle-joint, and the uniting medium is more vascular than the surrounding bone. The internal malleolus appears to have been broken off, and to have re-united. B. C. i. 1 M. 43. 3. 270. United Oblique Fracture of the Shaft of the Tibia. — Section of the lower half of a right tibia — macerated,, showing the above. Fractures of the Tibia. 141 The fracture has been oblique, but the broken ends have been in fairly good position. There is very little external callus, and the medullary cavity has been restored. B. C. I. 1. M. 46. i. 3. 271, United Oblique Fracture of the Shaft of the Tibia. — Sections of the lower end of a left tibia — macerated, showing the above. The line of fracture has run obliquely from the inside and above downwards and outwards. The ends over-ride, and are set at an angle which projects forwards. The broken ends are united by firm callus where they are in contact. The medullary cavity, where exposed, has been closed in, but in the interior the continuity of the canal has not been re-estab- lished. B. C. I. 1. M. 46. h. 3. 272. Badly united Fracture of the Tibia.—Plaster cast of a right leg and foot, showing the above. The patient had sustained a compound fracture by the fall of a heavy box on his leg. As the result of imperfect setting this displace- ment resulted, and he was admitted to the Royal Infirmarj', 13th Ajiril 1869, under Dr J. D. Gillespie, to have it put right. "A triangular piece of the tibia was cut away at the spot. No trace was to be found of the fibula, which must have been broken and mended merely by fibrous tissue. " The mal-position of the fracture must have rendered the leg quite useless for walking. G. C. 2675. Presented by J. D. Gillespie, F.R.C.S.E. 2. 273. Badly united Fracture of the Tibia.— Plaster cast of the same limb as the last, after operation. This cast was taken in June 1869. The patient could then use his leg perfectly. G. C. 2676. Presented by J. D. Gillespie, F.R.C.S.E. 142 Inji irks of Bone. 3. 274. Recent Compound Fracture of the Tibia.— Section of a left tibia and adjacent soft parts — injected, and in spirit — to show the above. The patient was a rather "done" man of 56. He was knocked over by an engine, and sustained a compound fracture of both bones of the left leg. An effort was made by antiseptic means to save the limb, but suppuration set in, and amputation became necessary. The stump was affected by a persistently spreading cellulitis, which resisted all treat- ment and eventually carried him of!'. The broken ends of the bone are smooth and bare, and would probably have necrosed in time. There was consider- able congestion of the medulla at and near the seat of fracture. G. C. 3200. Presented by Chaeles W. Cathcakt, F.R.C.S.E. 3. 275. Ununited Compound Fracture of the Tibia and Fibula. — Lower two-thirds of the shafts of a left tibia and fibula (blackened by putrefaction) — macerated, showing the above. The tibia has been broken about the middle, and the fibula lower down. The fracture has evidently been compound, and must have been followed by extensive suppuration, continuing for weeks and months. There has been great periostitic enlargement of both bones. The lower fragment of the tibia near the fracture is greatly eroded, and was probably necrotic, but no fragments are loose. The upper fragment of the tibia is enlarged, and its broken surface is hollowed out and very irregular. The upper frag- ment of the fibula is enlarged and condensed. A mass of new bone unites the lower end of the tibia to that of the fibula, but there has been no union between any of the other fragments. r. p. C. 158. 3. 276. Compound Fracture of the Tibia.— Portion of a fractured tibia — macerated, showing the above. Fractures of the Tibia mid Fihula. 143 This fracture has probably been compound. Some of the bone at the fractured spot has necrosed, and has been in process of separation. The bone near has been stimulated, and shows a crust of new periosteal bone. F. P. C. 2955. Presented by Professor John Thomson. 3. 277. Compound Fracture of the Tibia and Fibula.— UpjDer three-fourths of a left tibia and fibula, with a small portion of the outer malleolus — macerated, to show the above. IS'ewly formed cancellous bone fills the lower broken end of the tibia, and periosteal bone has been formed on both bones near the seat of fracture, while the rest of their surfaces shows opening out of the pores for blood-vessels. W. C. G. 12. UNITED FEACTURES OF THE TIBIA AND FIBULA. A. Of both bones at the same spot, i.e. by direct violence. 3. 278. Badly united Fracture of the Tibia and Fibula, about the Middle. — Plaster cast of a right tibia and fibula, showing the above. The bones are united at an angle directed forwards, and are thickened in their whole extent, but especially at the seat of fracture. G. C. 3331. From a Specimen in the Barclay Collection by James Kichaedson. 3. 279. Badly united Fracture of both Bones— Portion of a right tibia and fibula — macerated, showing the above. The fractured bones are united in a common mass. The lower fragment of the fibula is greatly thickened and runs into the upper end of the tibia. With the exception of the upper part of the fibula, the bones are greatly thickened and irregular on the surface, and a shelf of bone on the upper end of the 144 Injuries of Bone. lower fragment of the tibia has all the appearance of having been due to an ulcer of the soft parts over it. G. C. 3063. a. Presented hy'Bv.yA.^ C. Waller, F.R.C.S.E. 3. 280. Badly united Fracture of both Bones near their Lower End. — Lower two-thirds of a left tibia and fibula — macerated, showing the above. The lower fragment of the tibia is united to the upper fragments of both tibia and fibula, while the fragments of the fibula are also united to one another. B. C. I. 1. M. 38. 3. 281. Badly united Fracture of both Bones.— Lower half of a left tibia and fibula — macerated, showing the above. The patient was an old man, who died of malignant disease of the intestine. His leg had been injured by a reaping machine many years before his death, and he had walked without discomfort, though probably with a limp. The fracture has been at the same level in both bones. The ■■ fragments have over-ridden to a great extent. The lower fragment of the fibula is united to the upper fragment of the tibia as well as to its own upper fragment. There is con- siderable callus between the broken ends of the tibia. G. C. 3325. Presented hy Q-nAvajE.s W. Cathcakt, F.R.C.S.E. 3. 282. Badly united Fracture of both Bones near their Lower Ends. — Left tibia and fibula — macerated, showing the above. The lower ends are tilted forwards and slightly inwards from tlie seat of fracture, and thus form with the upper fragments an angle which projects backwards and slightly outwards. A bar Fractures of the Tibia and Fibula. 145 of bone unites the tibia and fibula at the seat of fracture. This form of mal-union is apt to occur if the heel be too much supported during treatment. W. C. G. 5. 3. 283. Badly united Fracture of both Bones near their Lower Ends. — Plaster cast of a right tibia and fibula, showing the above. The fracture in the fibula was four inches from the lower end, while in the tibia the fracture began about the same level, and ran obliquely backwards and downwards. The lower fragments were tilted backwards and inwards. A large amount of callus had formed round the broken tibia. The cast is taken from one in the Barclay Collection by James Kichardson. G. C. 3332. 3. 284. United Fracture of both Bones near their Lower Ends. — Lower ends of a left tibia and fibula — macerated, show- ing the above. The fracture has been oblique, and the break has occurred a little higher in the tibia than in the fibula. The union has been good, except that the tibia and fibula are united together close to the ankle. B. C. i. 1. M. 41. 3. 285. Ununited Comminuted Fracture of both Bones near the Lower End.— Lower third of a tibia— macerated, showing the above. The lower fragment of the fibula corresponding to that of the tibia adheres to it, but the upper part of the fibula is wanting. The upper fragment of the tibia has been split by the lower one, which has been driven into it. The broken surfaces are encrusted with newly formed bone round the fracture. The bones are eroded where they have been in contact, but have been mounted slightly separate to show the relationship. The fracture has probably been compound. G. C. 2780. K 146 Injuries of Bone. B. Fractures of both hones at different places, i.e. hj indirect violence. 3. 286. United Fracture of the Tibia a little below the Middle, and of the Fibula a few inches hig-her.— Left tibia and shaft of fibula — macerated, showing the above. The line of fracture in the tibia inclines downwards and inwards. The bones are each united at an angle, which projects back- wards, j)robably due to forward pressure of the heel during the treatment, B. C. i. 1. M. 35. 3. 287. United Fracture of the Tibia low down, and of the Fibula near its Head. — Right tibia and fibula- macerated, showing the above. The tibia has been broken at junction of its lower and middle thirds, and the fibula just below the head. The line of fracture in the tibia has been oblique from above and outside, downwards and inwards. The lower fragments are rotated slightly outwards, and the foot must have gone with them. The upper end of the tibia shows signs of arthritis deformans, and the semi-lunar cartilages have been ossified. B. C. I. 1. M. 46. e. 3. 288. United Fracture of the Tibia low down, and of the Fibula higher up. — Right tibia and fibula — macerated, showing the above. The tibia has been broken at the junction of its lower and middle thirds, and the fibula at the junction of its two upper fourths. The fracture in each bone has been oblique from above and outside downwards and inwards, and the broken ends in each case overlap considerably. B. C. i. 1. M. 37. 3. 289. United Fracture of the Tibia low down, and of Fractures of the Tibia and Fibula. 147 the Fibula higfheP up. — Right tibia and fibula — macerated, showing the above. As in the previous specimen, the tibia has been broken at the junction of the lower and middle thirds, and the fibula at the junction of its two upper fourths. The broken ends of the tibia are set at an angle, which projects slightly forwards. The obliquity of the fracture of the tibia is the same as in the last specimen. In the fibula the direction of the break is difficult to trace, owing to irregularities at the seat of fracture. The overlapping of the fragments is less than in the previous specimen. B. C. i. 1. M. 34. 3. 290. United Fracture of the Tibia near the Ankle-Joint, and of the Fibula about the Middle.— Right tibia and fibula — macerated, showing the above. The line of fracture in the tibia is oblique from the outer and posterior part of the bone downwards, inwards, and forwards. In both bones the fragments overlap, and form an angle directed slightly forwards. The fibula at the seat of fracture has, more- over, been pressed towards the tibia. The grooves for tendons, at the lower end of both bones, are increased in depth, probably from chronic congestion. F. P. C. 178. Presented by Professor John Thomson. FRACTURES OF THE TIBIA. {Some of these have probably been indirect fractures of both bones, as the line of obliquity corresponds to that seen in such specimens. ) 3. 291. United Fracture of the Shaft about the Middle. — Lower two-thirds of a right tibia — macerated, showing the above. The bone was divided longitudinally, but the condition of the interior is obscured by adipocere. The bone has evidently been comminuted, and the lower fragment is rotated inwards. B. C. i. 1. M. 46. d. 148 Injuries of Bone. 3. 292. United Fracture of the Shaft below the Middle- — Lower two-tliirds of a right tibia — macerated, showing the above. The line of fracture has apparently been from above and outside, downwards and inwards. The bones are set at an angle, which projects slightly backwards. This may have been, caused by raising the heel during the process of union. B. C. I. 1. M. 46. g. 3. 293. Badly united Fracture of the Tibia near its Lower End. — Eight tibia — macerated, showing the above. The line of fracture has been oblique from above and outside, downwards and inwards. The upper fragment over- rides on the inside, and is curved inwards near the upper end. The lower fragment has been rotated outwards. The interosseous membrane has been partly ossified. G. C. 2275, 3. 294. United Fracture of the Shaft near its Lower End.. — Plaster of Paris cast of a left tibia, showing the above. The line of fracture has been oblique from above and outside, downwards and inwards. The upper fragment over-rides- on the inner side of the lower one. Copied by permission from a specimen in the collection of Joseph Bell, F.R.C.S.E. G. C. 309L Presented by Chakles W. Cathcakt, F.R.C.S.E. 3. 295, United Fracture of the Shaft near its Lower End. — Plaster cast of a left tibia, showing the above. The line of fracture runs downwards and inwards, and the upper fragment over-rides on the inner side of the lower one. The bones are joined at an angle which projects slightly back- Fractures of the Tibia and Fibula. 149 wards, and the lower fragment has been rotated outwards, and the foot must have been carried with it. Copied by permission from the collection of Joseph Bell, F.R.C.S.E. G. C. 3090. Presented by Charles W. Cathcart, F.R.C.S.E. 3. 296. United Fracture of the Shaft near its Lower End. — Lower two-thirds of a left tibia — macerated, showing the above. The line of fracture runs downwards and inwards. The ends overlap, but the union is otherwise good, except that there is an interval between the fragments at the back. Some marks of chronic periostitis are seen near the fracture. B. C. I. 1. M, 46. f. 3. 297. United Fracture of the Shaft, which had an Ulcer over it. — Lower three-fourths of a right tibia— macerated, showing the above. The fragments are set at an angle, which projects slightly forwards. At the seat of fracture, at the inner side, the surface of the bone is opened out and rough, as if there had been an ulcer over it. At other places the surface shows signs of periostitis. B. C. i. 1. M. 40. a. S. 298. Ununited Fracture of the Shaft, a little below the Nutrient Foramen. —Portions of a right tibia and fibula — macerated, showing the above. The fragment of the tibia has a conical lower end, and is united externally to the fibula by a thick mass of new bone. The lower fragment of the tibia is wanting. Note that the fibula, below its union with the tibia, is thickened, as if taking on the function of the missing fragment of the latter. B. C. I. 1. M. 46. a. 150 Injuries of Bone. 3. 299. Ununited Fracture of the Shaft, with Compen- sating" Hypertrophy of the Fibula. — Plaster cast of the bones of a right leg, showing the above. The original is in the Barclay Collection, and shows the smoothing of the broken ends of the tibia. The fragments are set at an angle backwards ; the fibula, although much thickened, is bent in a similar direction. Another copy of the same specimen has been placed in the General Pathology Series, to illustrate Compensating Hypertrophy. G. C. 3280. FRACTURES OF THE FIBULA. 3. 300. Various Fractures of the Fibula.— Six fibulae — macerated and mounted together — to illustrate the above. In one there is a double fracture. The others exhibit more or less irregularity of union and overlapping of the frag- ments. B. C. I. 1. M. 46. j. 3. 301. Fracture of the Fibula. — Fragment of a fibula — macerated, showing the above. The bone is irregularly united. B. C. i. 1. M. 46. j. 3. 302. Fracture of the Fibula. — Portion of a right fibula — macerated, showing the above. The bone is united at an angle, which projects forwards and inwards. B. C. i. 1. M. 46. 3. 303. Ununited Fracture of the Fibula— Lower four- fifths of a right fibula — macerated, showing the above. The upper portion is wanting. Some new bone has been thrown out at the seat of fracture. Fractures into the Ankle-Joint. 151 and at other places the broken surface has been smoothed over. The vascular pores are enlarged over the greater part of the surface. The fracture has probably been compound. B. C. I. 1. M. 46. k. FRACTURES INTO THE ANKLE-JOINT. {a.) Involving chiefiy the Tibia. 3. 304. Comminuted and Splitting Fracture of the Tibia» involving" the Ankle-joint. — Lower half of a right tibia — macerated, showing the above. The fracture has begun about six finches above the joint, and has run down in an irregularly spiral manner into the lower end, the fissures meeting one another, so that portions of the bone have become detached. There are marks of periosteal activity on the fragments Apparently, therefore, the fracture has been compound, and amputation has been performed a few weeks after the injury. G. C. 175. b. 3. 305. Fracture of the Tibia, involving the Ankle-joint — comparatively recent. — Inner half of a section of the lower end of a left tibia, astragalus, and os calcis — muscles dissected off — in spirit, showing the above. The line of fracture has passed from above and behind downwards and forwards, and seems to have just reached the ankle-joint. The lower fragment of the tibia is displaced back- wards. The broken surfaces of the cancellous tissue and adjacent periosteum seem to be infiltrated with recent lymph. G. C. 3305. 3. 306. Comminuted Fracture of the Lower End of the Tibia, involving the Ankle-joint.— Lower ends of a 152 Injuries of Bone. left tibia and fibula with the astragalus — macerated, showing the above. The tibia has been severely comminuted and split, and • several of the fragments are wanting. The fibula seems also to have been broken about five inches from its lower end. G. C. 825. ■ Presented by Sir George Ballingall. 3. 307. Compound Comminuted Fracture of the Lower End of the Tibia, involving* the Ankle-joint— Astragalus and lower half of a right tibia and fibula — muscles cleaned off — in spirit, showing the above. The lower end of the upper fragment of the tibia is bare, and some of the portions of the lower fragment have been removed, so that the articular surface is no longer recognisable. The fibula has been broken about four inches from the lower end, and the fragments overlap. The upper surface of the astragalus is almost completely denuded of cartilage. The soft parts which remain round the ankle appear infiltrated with lymph. Severe suppuration has evidently followed the injury. G. C. 1055. Presented by Professor James Russell. 3. 308. Badly united Fracture of the Lower End of the Tibia into the Ankle-joint. — Right tibia, to which a small portion of the fibula adheres — macerated, showing the above. The union is very irregular, and a piece of the fibula has become attached to the tibia at the seat of fracture. The rest of the fibula is wanting. The main fracture has apparently been from above downwards and forwards, but the lower fragment has been comminuted into the ankle-joint. There is a slight forward bend at the point of union. The upper articular surface is set obliquely to the shaft, as in genu varum, i.e. with the shaft of the tibia sloping downwards and inwards. B. C. i. 1. M. 39. Fractures into the AnMe-Joint. 153 3. 309. United Fracture of the Tibia and Fibula into the Ankle-joint. — Anterior half of a section of the lower end of a right tibia and fibula — macerated, showing the above. The fracture in the tibia has been oblique from above and inside downwards and outwards, while the fracture in the fibula has been from behind downwards and forwards. The lines of fracture in the two bones have met at the interosseous space, just above the ankle-joint. The fracture in each case is soundly united, and the two bones are welded together immediately above the ankle-joint. B. C. I. 1, M. 46. b. 3. 310. Fracture of Tibia into the Ankle-joint, with Anchylosis. — Right tibia, with section through its lower end, passing also through an anchylosed astragalus and os calcis — macerated. Evidently this has been a comminuted fracture of the lower end of the tibia, with some displacement forwards of the lower fragment. There is an osseous anchylosis between the tibia and the astragalus, and between the astragalus and the os calcis. G. C. 364. (h.) Chiejiy involving the Fibula. 3.311. Recent Compound Fracture of the Fibula, Astragalus, and Os Calcis.— Lower ends of a right tibia and fibula, with the astragalus, scaphoid, cuboid, and part of the OS calcis — macerated, showing the above. The patient was a young man, whose foot had been badly crushed. An effort was made to save the limb, but the wound became septic, and amputation could not be avoided. The fibula is comminuted and split into the ankle. The astragalus is also split, and the greater part of the os calcis was removed as loose fragments. G. C. 33/6. Presented by Charles W. Cathcart, F.R.C.S.E, 154 Injuries of Bone. 3.312. Recent Severe Form of Pott's Fracture from a Crush. — Part of a right leg and foot, dissected to show the relation of parts in the above — in spirit. The patient was a mason whose foot was severely crushed by a stone. Gangrene set in, and a few days after the accident amputation of the limb became necessary. There is a comminuted fracture of the fibula just above the ankle. The inner malleolus has been broken off and comminuted. The peroneal tendons are displaced forward. Besides the above injuries, the posterior tibial artery was torn across, and the soft parts were greatly bruised. G. C. 2849. Presented by P. H. Maclaken, Esq. 3. 313. Recent Pott's Fracture from a Crush.— Lower ends of a right tibia and fibula, with the astragalus, scaphoid, and os calcis attached — muscles cleaned off, and in spirit, showing the above. The fore part of the foot had been so severely crushed that amputa- tion was necessary. The specimen illustrates the injuries usually met with in Pott's fracture, the inner malleolus being broken off, and the fibula fractured a few inches above its lower end. The external lateral ligaments were divided by the surgeon, who amputated the leg, but the injury had left both lateral ligaments of the ankle intact. G. C. 2779. Presented by Chakles W. Cathcart, F.R.C.S.E. 3. 314. Fracture of the Fibula in Pott's Fracture.— Lower end of a right fibula — macerated, showing the above. The patient, a man aged 44, slipped and twisted his foot under him. When admitted to the Royal Iniirmary, Edinburgh, the lower part of the leg was very red, and was much swollen. The patient suffered from restlessness and want of sleep. In four days he became delirious. In spite of opiates and other treatment, he grew worse, and died comatose the ninth day after the accident. "The fractured surfaces were highly PoWs Fracture. 155 vascular, covered with soft downy granulations, and evidently in the progress towards re-union." The bone has given way irregularly, and has been some- what comminuted. Some new periosteal bone is seen on the lower end of the upper fragment. G-- C. 1098. Presented by Sir Geokge Ballingall. 3. 315. Severe Form of Pott's Fracture— Eight foot and greater part of the leg, with the skin removed, except round the inner malleolus, where the bone projected after sloughing. The muscles are dissected, and the specimen is mounted m spirit to illustrate the above. A. B., aged 35, while intoxicated, slipped on the ice and fell, on 12th January 1837. He attempted to walk at first, but being unable to do so was afterwards driven home. Next day the fracture was reduced. In twenty- four hours afterwards great swelling came on, "the skin presenting a dark blush and numerous large dark-coloured phylctenaj." The splints were removed and leeches were applied. Eight hours after- wards the displacement was renewed by an involuntary muscular movement. The redness extended to the thigh, and over the inner malleolus a elough formed 3 x 2^ inches. On the 21st January an attack of delirium tremens came on and"lasted for three days, during which the leg was much tossed about. Eventually the ankle-joint was opened into, and an abscess formed on the outer side. On the 1st of February the limb was amputated below the knee and the patient did well. There is a fracture of the fibula about two inches above the malleolus, also rupture of the internal lateral ligament, and dislocation of the whole foot outwards. A piece of cane indicates how the ankle-joint was opened into. G. C. 1975. Presented by Sir George Ballingall, 1837. 3. 316. Pott's Fracture, with Stiffness of the Ankle.— Lower half of a right tibia and fibula— macerated, showing the above. "The joint upon dissection exhibited marks of former injury and disease, being stiff, and the ligaments deprived of their natural structure. The muscles on the back of the leg were reduced almost to common cellular texture." The outer malleolus has been fractured obliquely, and the 156 Injuries of Bone. lower fragment has been pushed up. There is mucli irregularity at the tip of the inner malleolus, round the articular margins of both bones, and at the grooves for tendons. This must have been a severe case of Pott's fracture, followed by deformity and stiffness. B. C. i. 1. M. 46. c. 3. 317. United Fracture of the Fibula, from a Case of Pott's Fracture. — Left fibula of an old woman — macerated, to show the above. The bone has been broken transversely about an inch and a half from its lower end. The whole bone is exceedingly light and fragile, and several from the same old woman have been macerated, to illustrate senile osteo-malacia (see series 6). Cx. C. 3224. Presented htj Chakles W. Cathcart, F.R.C.S.E. 3. 318. Unreduced Pott's Fracture. — Plaster cast of a left foot, showing the above. The foot is displaced greatly outwards, and the heel is drawn backwards. The foot can have been of little or no use in walking. G. C. 3289. Presented by Charles "W. Cathcart, F.R.C.S.E. 3. 319. Fracture of the Os Calcis. — Left os calcis — macerated, to show the above. The patient was a man 60 years of age. A wheel passed over the foot ; gangrene followed, and amputation was performed. The gangrene returned and the man died. There is a depression of the compact layer on the outside, with some comminution, but no injury to the bone elsewhere. G. C. 3250. Fractures of the Tarsal Bones. 157 3. 320. Fracture of the Os CalciS. — Lower end of a left tibia and fibula, with the astragalus and remains of a broken os calcis — muscles dissected off and in spirit. A young woman, 19 years of age, leaped from a window two floors from the street, and fractured the os calcis into six or eight fragments, one of which projects into the back part of the ankle-joint. Several weeks after the injury, in consequence of disease of the joint and abscesses about the foot, associated with necrosis, amputation of the leg was performed. The patient recovered. The greater part of the os calcis seems to have been crushed up behind and to the outer side of the astragalus. Some new bone has been formed on the sides of the original os calcis, while at the back a cavity extends into its substance, near the orifice of which there is a piece of dead bone. G. C. 1981. Presented by Alexander Watson, Esq., March 1839. 3. 321. Fracture of the Os Calcis.— The lower end of a right tibia, fibula, astragalus, and portion of the os calcis — cleaned, and in spirit. The upper portion of the os calcis has been comminuted, and is separate from the lower. The broken surfaces are apparently covered by lymph. The articular cartilage upon the astragalus and outer malleolus is roughened and partially removed. This has probably been a case of compound fracture of the OS calcis, followed by inflammation and suppuration. G. C. 3504. GUNSHOT FEACTURES OF THE LOWER LIMB. {a.) Chiefly from Waterloo. 3. 322. Old-Standing" Gunshot Fracture of the Ilium.— Left ilium — macerated, to show the above. A portion of the bullet is wired in position. "This man had been wounded by a small rifle ball. It had penetrated the ilium, and lay just within the bone, being prevented 158 Injuries of Bone. from penetrating into the pelvis by the tough ligamentous attachments on the inside of the bone. He had come up to town to receive his pension, and in some of his irregiilarities in living the wound of the hip, which was not healed, became suddenly inflamed, with an attack of fever, and thus, several months after being wounded, he was cut ofl". The ball is attached, and seen to be a iiattened piece of lead. The bone exhibits the consequences of inflammation, absorption, and granulation, since the hole made by the ball is enlarged by absorption, and the surface is rough with granulations of bone. In the neighbourhood of the bullet there has been a perforation of the bone, and the walls of this perforation are necrotic and carious. Eound about the perforation on both aspects new bone has been thrown out, and the vascular channels are enlarged all over. B. C. xvii. 12. 3. 323. Old-standingr Bullet Wound of the Pubic Arch.— Front portion of a pelvis — muscles dissected off and in spirit, showing the effects of the above. The patient lived a considerable time after the wound, and died of hydatids of the liver. A mass of condensed connective tissue surrounds the track of the wound, which has been on the left margin of the pubic arch. B. C. xvii. 13. 3. 324. Head of a Femur carried off by a Bullet.— Head of a femur in which a bullet is embedded — macerated. ' ' This soldier received a musket ball in the hip. It was discovered that the thigh-bone was fractured, but he was dying of inflammation and pain of the abdomen. On dissection the head of the thigh-bone was found in the abdominal cavity, and on inspection it will be seen that the leaden ball was in the centre of the head of the thigh-bone. It is clear, therefore, that the force of the ball had been communicated to the head of the thigh- bone, where it had forced the acetabulum, and, by breaking through the pelvis, had got into the cavity of the abdomen." B. C. XVII. 15. 3. 325. Comminuted Gunshot Injury to the Head of the Gunshot Fractures of the Femur. 159 FemUP. — Small portion of the head of a femur — macerated, to show the above. The patient was shot in the hip at "Waterloo. He would not consent to any operation, and died. B. C. XVII. U. 3. 326. Bullet lodg-ed in the Neck of the Femur.— Upper end of a right femur — macerated, showing the above. The patient was a soldier who fought at "Waterloo. A fissure extends from the neck into the head on the front and back. The bullet is a round one, and lies in the front of the neck, in a cavity considerably larger than itself. The size of the cavity is probably due to suppuration round the bullet, as the bone texture that remains is carious, and at places necrotic, one piece on the lower side being in process of separation. The surface of the neck is opened out at places, and has a slight crust of new bone upon it. Figured in Hennen's "Principles of Military Surgery," 1st edition, plate ii. fig, 4. F. P. C. 213. Presented by Professor John Thomson. 3. 327. Gunshot Fracture of the Great Trochanter.— Upper end of a right femur- macerated, showing the above. A round bullet is shown embedded in fragments of the great trochanter, which are wired in position. This is another instance of the effectual barrier which ligament oflFers to the course of the ball. He was a prisoner endeavouring to escape from the prison-ship, and was shot while in the boat. He died of irritation. The bullet has struck the back of the neck, and has travelled from within outwards, for, after ploughing a groove in the back of the neck, it has split and lodged in the great trochanter. Figured in Bell's "Observations on Injuries of the Spine and Thigh Bone," pi. iv. fig. 5. B. C. XVII. 16. 160 Injuries of Bone. 3. 328. Gunshot Fracture immediately below the Tro- chanter.— Upper end of a left femur — macerated, showing the above. The patient was a soldier who fought at "Waterloo. The fracture is an irregular one. A fissure runs up into the neck on the inner side, and another into the great tro- chanter on the outer side. From the commencing necrosis at the seat of fracture on the outer side, and from marks of inflam- mation at other places, there has evidently been suppuration for days or weeks after the injury. F. P. C. 216. Presented by Professor John Thomson. 3. 329. Gunshot Fracture in the Upper Third of the Shaft of the Femur. — Upper end of a left femur — macer- ated— showing the above. The specimen is from a soldier who fought at "Waterloo. The fracture has been irregular, and a fissure runs up upon the outer side. A portion of bone on the inner side at the seat of fracture has necrosed, and has been in process of separation. The rest of the bone has evidently been inflamed. F. P. C. 215. Presented by Professor John Thomson. 3.330. Gunshot Fracture of the Middle of the Shaft of the Femur. — Lower two-thirds of a right femur — macerated, showing the above. The fragments are Avired in position. All the portions were driven among the muscles. The man lay on the field of Waterloo several days. The bone has been severely comminuted for about four inches, but there are no fissures beyond the comminuted area. Roughness, due to periostitis, is visible over the whole of the shaft, and on the fragments as well. Smooth patches on the frag- ments and main part of shaft indicate necrosed pieces of bone which would have separated in time. The man must have lived many days, if not several weeks, before amputation was performed. B. C. xvii. 42. GunsJiof Fractures of the Femur. 161 3. 331. Gunshot Fracture of the Lower Third of the Shaft of a Femur. — Lower two-thirds of a right femur — fragments wired in position — macerated, to illustrate the above. The limb was amputated in the Gendarmerie after the battle of Waterloo. The bone has been severely comminuted for about five inches, and fissures run down in the lower fragment towards the knee. On the shaft and on most of the fragments there are some marks of inflammation, but less advanced than those seen in the previous specimen. B. C. xvii. 43. 3. 332. Gunshot Fracture of the Lower Third of the Shaft of a Femur. — Lower portion of the right femur of a young adult — macerated, to show the above. The patient was wounded at Waterloo. A fragment of bone has been driven into the medullary cavity. The upper and inner portion of the fractured margin has necrosed, and has been in process of separation, while upon the shaft near it there is a crust of new periosteal bone. These show that inflammation and suppuration had been going on for many days after the injury (see 3. 342). F. P. C. 236. Presented by Professor John Thomson. 3. 333. Gunshot Fracture of the Shaft of a Femur.— Portion of the shaft of a femur — macerated, to show the above. The injury was received at the battle of Waterloo. As in the previous specimens, portions of the broken edge have necrosed, and have been in process of separation. The rest of the bone has been inflamed and opened out, and some new periosteal bone has been deposited. F. P. C. 226. Presented by Professor John Thomson. 3. 334. Gunshot Fracture of the Shaft of a Femur. — L 162 Injuries of Bone. Portion of the shaft of a femur — macerated, to show the above. The wound was received at the battle of Waterloo. The fracture has been oblique, but not comminuted. Near the seat of fracture there have been large deposits of new periosteal bone, but the margins of the fracture are smooth and apparently necrotic, which explains why there has been no attempt at union. In this, as in the previous cases, there has evidently been a septic compound fracture. Figured in Hennen's "Military Surgery," 1st edition, plate ii. fig. 2. F. P. C. 222. Presented by Professor John Thomson. S. 335. Pistol-shot Fpacture of the Shaft of the Femur.— Lower part of the right femur of a woman — macerated, to show the above. The fragments are wired in position. "Martha Holloway was shot with a horse pistol, said to be loaded with four slugs, and at the distance of two feet from her. The wound was on the fore and outer part of the thigh, and was of the size to let in the points of three fingers. When the finger was passed into the wound, a number of sharp splinters were felt. The lower part of the thigh-bone was greatly retracted behind the upper portion, and the limb was singularly misshapen. She refused to submit to amputation. The wound was enlarged and the fascia slit upwards and downwards. Two large portions of bone were ex- tracted. The slugs could not be felt. Portions of slugs and dead pieces of bone were discharged at diS"erent periods. Large abscesses extended through the thigh, and there was no union of the bone eiglit months after the accident, when the limb was amputated." The loose pieces of lione, wired to the bone near the seat of fracture, have, from the character of their surface, evidently been formed for the most part after the injury. On the main pieces the new bone thrown out and the roughened condition of the surface indicate periosteal irritation, while the spongy appearance of the broken ends points to a septic form of caries, Avhich must have prevented union. B. C. XVII. 59. Gunshot Fractures of the Femur. 163 3. 336. Gunshot Fracture of the Shaft of the Femur.— Portions of bone from the above case — macerated : (a) A smooth piece removed immediately after the injury ; (&) two necrosed pieces which were loosened and detached by the granulations; (c) a portion, consisting of new bone, with a small piece of the original bone on its under surface. B. C. xvii. 59. 3. 337. Gunshot Fracture of the Shaft of the Femur.— Fragments removed from a case of the above — macerated. The specimen was taken from a soldier wounded at AVaterloo. The main fragments are three in number, but to the middle one a smaller fragment — driven into the medullary cavity — is adherent by newly formed bone. Upon all the fragments there has been a deposit of bone. This is seen mostly upon the periosteal surface, but at other places also. Thus on the middle fragment a fine spongy projection on the medullary aspect can easily be distinguished as new bone from the neighbouring cancellous texture. Again, oa the lowest • fragment new bone has grown from the broken margin of a portion of the compact tissue. Portions of the broken margin on the two lower pieces are smooth, and have evidently been in process of separation. See Henueu's "Principles of Militaiy Surgery," p. 137, pi. i. fig. 3. P. P. C. 227. Presented by Professor John Thomson. 3. 338. Gunshot Fracture of the Femur. — Fragments removed from cases of the above — macerated. They illustrate characters noted in some of the foregoing specimens. P. P. C. 228. 3. 339. Necrosis of the Stump of a Femur after Amputa- 164 Injuries of Bone, tion for Gunshot Fracture. — Portion of the shaft of a femur — macerated, to show the above. The wound was received at Waterloo. The sawn surface and the bone near it are smooth, and have been dead. Beyond that the surface has been eroded by granulations, and further up it is encrusted with new periosteal bone. This is raised as an irregular collar, behind the groove of separation, and beyond that it fades gradually off into the general surface of the bone. Figured in Hennen's "Military Surgery," 1st ed., plate iv. fig. 3. F. P. C. 223. Presented by Professor John Thomson. 3. 340. Necrosis of the Stump of a Femur after Amputa- tion for Gunshot Fracture. — Small portion of the shaft of a femur — macerated, showing the above. The wound was received on the field of Waterloo. This specimen was formerly entered as a case of gvinshot fracture, but as its features are essentially similar to these of the last, the title now adopted seems more suitable. P. P. C. 221. Presented by Professor John Thomson. 3. 341. Sequestrum after Amputation of the Femur for Gunshot Fracture. — Portion of the shaft of a femur — macerated, showing the above. The patient was wounded at Waterloo. As in the previous specimen, the sawn surface and neigh- bouring bone are unchanged from what they were at the time of operation. Beyond that, the bone has been pitted and eroded by the granulations during the process of separation. Figured in Hennen's " Principles of Military Surgery," plate x. fig. 4. R P. C. 225. Presented by Professor John Thomson. 3, 342. Gunshot Fracture of the Lower End of the GuTishot Fractures of the Femur. 165 Femur. — Lower portion of the shaft of a femiu- — macerated, to illustrate the above. The knee had been completely detached by grape-shot at Waterloo. ' ' This poor wretch' was not relieved by amputation for fifteen days after the battle." The line of fracture is irregular, and two fissures run upwards for about three inches. At the seat of fracture, the bone is smooth. Round this there is a shallow groove of separation, while beyond that the surface is rough, partly from a slight crust of new periosteal bone, and partly from the opening up of vascular pores. It is important to note the extent to which these changes have been carried in a fortnight. B. C. XVII. 41. 3. 343. Gunshot Fracture of the Lower End of a Femur. — Lower end of a left femur — macerated, to show the above. One or two fragments have been driven into the interior. The patient was wounded at Waterloo. The marks of periostitis indicate that the patient must have waited many days before amputation was performed. The irregular growth of bone round the articular surface has been due to arthritis deformans previous to the injury. r. p. C. 237. Presented hij Professor Johk Thomson. 3. 344. Comminuted Gunshot Fracture of the Lower End of the Femur. — Lower two-thirds of a left femur — macerated — fragments wired together to illustrate the above. "The knee, in this case, was completely driven off. It was fourteen days before anything was done for the patient. The portion marked off by the black line projected. Amputation, very high, was necessary, on account of the great bag of matter." The articular end of the bone is in three pieces, and some fragments of the adjacent part of the shaft are missing. The upper fragment has indications of necrosis on the part which 166 Injuries of Bone. protruded, and there has been periostitis ahove that, similar to what was noted in No. 3. 342. Some erosions are present upon the surface of the lower fragments. B. C. xvii. 33, 3. 345. Severe Gunshot Fracture of the Lower End of the Femur. — The lower end of the shaft of a right femur — macerated. Several pieces are missing, and the remaining fragments are wired together. The wound was received at Waterloo. The condylar portion of the bone has been split in several directions. The joint has been opened into, and, from the erosion of the articular surface, must have been the seat of suppuration. The lower end of the upper fragment shows changes similar to those noted in No. 3. 342 and others. F. P. C. 239. Presented hy Professor John Thomson. 3. 346. Gunshot Injury of the Inner Condyle of the Femur^ — Lower half of a right femur — macerated, to show the above. This wound was received at Corunna. Suppuration of the limb followed the injury, and extended among the muscles of the calf. The- patient was exhausted by hectic fever when amputation was performed. In Sir Charles Bell's drawing of this specimen ("Operative Surgery," plate ii. fig. 1) the ball is seen lodged in the depression, in front of the inner condyle. The walls of the cavity have some necrotic fragments still adhering to them, but at other places the bony lining has been somewhat condensed. The outer shell of bone is splintered. B. C. xvii. 29. 3. 347. Gunshot Injury of the Back of the Outer Condyle of the Femur. — Lower end of a left femur — macerated, to illustrate the above. A musket ball had lodged in the back of the outer condyle at the battle of Waterloo. GiinsJwt Fractures of the Femur. 167 The back of the inner condyle is wanting, and a circular depression above it indicates where the bullet lay. Portions of the bone which formed the bed of the bullet have necrosed, and have been in process of separation. The joint had evidently been acutely inflamed, and the articular surfaces have been eroded. There is a small crust of new periosteal bone above and behind the condyles. F- P- C. 240. Presented hy Professor John Thomson. 3. 348. Bullet lodg-ed in the Condyles of the Femur.— Lower end of a femur — with the patella and adjacent parts of tibia and fibula dissected, and a section removed from the outer condyle to illustrate the above — in spirit. A Russian General, Baron Driesen, was struck by a musket-ball on the inner condyle of the left femur at the battle of Borodino on the 6th of September 1812. The ball lodged near the outer condyle. Inflammation and suppuration followed, causing great pain. Various attempts were made to remove the ball by dilating the wound with sponge tents but without success. During 1815 and until March 1816 the wound remained closed. At this time the parts became greatly swollen and very painful, the old wound reopened, and an abscess on the outer side was evacuated. Some improvement followed, and a German surgeon poured large quan- tities of mercury into the sinus in the hope of dissolving the bullet. This was followed by intense pain and numerous abscesses round the knee- joint. As these symptoms continued, the limb was amputated above the knee by Sir Charles Bell on the 7th of January 1817. For a time considerable pain and swelling remained in the stump, but these gradually subsided, and the Baron left London for St Petersburg in May of the same year. Sir Charles Bell found mercury lodged in different abscesses round the joint and inflammatory thickening round the popliteal nerves. The patella, femur, and tibia were anchylosed by bone. An encrustation round the bullet has obscured its metallic character, but indicates its position. (See Bell's "Surgical Observations," p. 431.) B. C. xvii. 38. 3. 349. Bullet lodged in the Condyles of the Femur. Section removed from the foregoing specimen— macerated. 168 Injuries of Bone. This piece shows the bony anchylosis between the patella and the femur, and a depression in the bone which formed the bed of the bullet. B. C. xvii, 38. a. 3. 350. Bullet lodged in the Condyles of the Femur.— Popliteal nerves, with adjacent muscle and lymphatic gland, from the same case as the foregoing. Minute globules of mercury can be recognised on the section of the lymphatic gland and in the surrounding tissue. There is great matting of fibrous tissue round the nerves. B. C. XVII. 39. 3, 351. Bayonet Wound of the Lower End of a Femur.— Lower end of a right femur — macerated, showing the above. The bayonet wound was received at Waterloo. The leg was shattered, and required amputation above the knee. " Although, in this case, the question of amputation was decided by the shattered condition of the bones of the leg, the wound in the head of the femur {sic) is interesting to us, as being that which, although apparently slight, is attended with the most serious consequences. The wound is on that part of the bone, which implies that the point of the bayonet has penetrated the capsule of the joint. It was, in short, a punctured Avound, which, if inflammation be not prevented, may be followed, as in the present instance, by suppuration within the joint " (Sir Charles Bell). [Instead of " inflammation," we would now say " sepsis."— C. W. C] There is an indentation by the bayonet on the side of the inner condyle. B. C. xvii. 37. 3. 352. Bullet Wound of the Head of the Tibia.— Upper half of a right tibia — macerated, showing the above. The round bullet which lodged at the back has been wired in position. The wound was received at Corunna. Gunshot Fractures of the Tibia. 169 " There was here, of course, a breach of the capsule of the joint. The consequences were great swelling of the whole extremity, matter in a cavity of the knee-joint, and a diffused .abscess under the gastro-cnemii. The limb was properly amputated. This was from Corunna. It led me to expect what I saw afterwards at Waterloo " (Sir Charles Bell). It should be noted that the wound of entrance is smaller than the bullet, also that the wound of exit is the larger and more irregular of the two. Some splinters of bone have been loosened at the wound of exit, and a fissure extends down- wards for about four inches. See Sir C. Bell's "Operative Surgery," pi. ii. fig. 2, and pi. xi. B. C. XVII. 28. a. 3- ^53. Bullet Wound of the Head of the Tibia.— Photo- graph, from a drawing by Sir Charles Bell, of the limb, before operation, from which the previous specimen was taken. G. C. 3561. :3. 354. Gunshot Fracture of the Head of the Tibia.— Upper end of a right tibia — macerated, showing the effects of the above. The inner tuberosity, which had been shot off, is ■wired in position. The specimen was taken from a soldier who fought at Waterloo. The ball has apparently penetrated from within outwards, and has also split off the inner tuberosity. The bone in the track of the bullet has been necrotic, and evidently inflammation .and suppuration have attacked the knee-joint. The articular surface is rough and opened out, and the surface of the bone generally is in a similar condition. F. P. C. 244. Presented by Professor John Thomson. 3.355. Gunshot Fracture of the Tuberosities of the Tibia. — Upper half of a left tibia and fibula of a young adult 170 Injuries of Bone. — macerated, to show the above. The epiphyseal line is still visible. " The ball passed through the head of the tibia, and must have broken upon the continuity of the capsular membrane ; but this man got so well as to have been brought up to York Hospital for the purpose of being examined for a pension, when irritation and inflammation commenced, which made it neces- sary to amputate " (Sir Charles Bell). The bullet has perforated, without splitting, the front of the head, New bone has been formed round the openings, especially on the outer side, and also on the front of the tibia for about three inches below the injured spot. There is a slight deposit on the head of the fibula. B. C. xvii. 30. 3. 356. Bullet lodged in the Upper End of the Tibia, fol- lowed by acute Osteo-myelitis and Necrosis of the Shaft. — Upper two-thirds of the right tibia of a young adult (epiphyseal line still visible) — macerated, to show the above. The Avound was received at the battle of Waterloo. Abscess and caries made amputation necessary. The bullet, which is a round one, is lodged intact in a large cavity in the cancellous tissue at the back of the upper end of the bone. On the front of the shaft a large part of the compact tissue has necrosed. This dead piece has been partially separated above, while below its surface has been partly absorbed by granulations, and is in consequence very rough. A piece cut out of it shows that the separation was also proceeding from below. The rest of the shaft, especially at the back, is encnisted with new periosteal bone. Apparently, therefore, an acute osteo-myelitis following the injury produced by the bullet has ended in necrosis. B. C. xvii. 32. 3. 357. Bullet lodgred in the Upper End of the Tibia, followed by Osteo-myelitis and Necrosis of the G^mshot Fractures of the Tibia. 171 Cancellous Tissue. — Upper end of the left tibia of a young adult — macerated, to show the above. A bullet is wired in a cavity in the head. The injury was sustained at Waterloo. The extensive suppuration made amputation necessary. The space round the ball contains a large fragment of cancellous bone, and some new periosteal bone has formed down the front of the shaft, but for a short distance only. B. C. XVII. 31. 3. 358. Bullet lodged in the Knee, followed by Tuberculosis. Upper end of a right tibia — macerated, showing the above. A bullet is wired in position on the top of the outer tuberosity. The articular surface is very irregular, being occupied by excavations. The walls of these are opened out, although one at the back shows signs of healing. On the outer condyle an island of necrotic bone remains, with its articular surface unchanged, and surrounded by a deep trench. At one or two other places similar though smaller islands are seen. These appearances are identical with those seen in advanced tuber- cular disease. The surface of the bone below the articulation is much roughened by newly formed periosteal bone. This indicates that sepsis has accompanied the tubercular process. F. P. C. 245. 3. 359. Gunshot Fracture of the Tibia and Fibula.— Right tibia and fibula — macerated, showing the above. The fragments are wired together. "This may give a picture of the state of the French wounded (Waterloo), who were brought into Brussels upon waggons, fourteen days after the battle, and were never dressed before that time " (Sir Charles. Bell). The part of the tibia struck has been comminuted into- many pieces, most of which are loose. Fissures, however, do not run beyond the shaft. The fibula has been broken across. 172 Injuries of Bone. The surface of the main fragments of the tibia, as well as of some of the smaller pieces, indicates suppuration and inflam- mation as in 3. 344. B. C. xvii. 44. 3. 360. Gunshot Fracture of the Tibia and Fibula.— Lower three-fourths of a right tibia and fibula — macerated, showing the above. The patient was wounded at Waterloo by a musket ball, and received no assistance whatever until fourteen days after the battle. The limb was amputated at the Gendarmerie. It may be noted that while the part of the tibia struck by the ball has been comminuted into small pieces, the remaining portions of the shaft are unaffected, with the exception of one fissure on the lower piece. A slight crust of new periosteal bone has formed on the main portions of the shaft, as in the previous case. B. C. xvii. 45. 3. 361. Gunshot Fracture of the Shaft of the Tibia and Fibula. — Portions of a right tibia and fibula — macerated, showing the above. " Example of the effect of a ball striking the cylinder of the tibia." Like the two previous specimens, this one shows comminution at the point struck, with little or no splitting of the remainder. The slight crust of new periosteal bone indicates a similar period of about fourteen days before the limb was amputated. B. C. xvii. 46. 3. 362. Gunshot Fracture of the Shaft of the Tibia.— Small portions of a tibia driven off by a musket shot — mace- rated. B. C. XVII. 48. 3. 363. Gunshot Fracture of the Tibia and Fibula.— Gunshot Fractures of the Tibia. 173 Lower three-fourths of a right tibia and fibula — macerated, showing the above. The fragments are wired in position. "The fracture of the tibia and fibula would not have warranted amputation, had the foot not also been shattered. Remark. — Indeed, if the majority of these eases of gunshot fracture had been treated early, and free incisions made down to the bone, many of them might have done well, without amputation. It was the circumstances in which they were found that made amputation necessary, and at the same time almost a hopeless measure " (Sir Charles Bell). The fibula is broken irregularly, and the tibia comminuted. The comminution of the tibia, however, is less than in the previous specimens, but the splitting of the remaining portions of the shaft is somewhat more extensive. A layer of newly formed periosteal bone, slightly thicker than in the preceding specimens, is seen above and below the seat of injury. B. C. XVII. 47. 3. 364. Gunshot Fracture of the Tibia.— Upper end of a left tibia — macerated, to show the above. One loose piece is wired in position. The wound was received at "Waterloo. Necrosis has been present at the seat of fracture, and the line of separation has begun. New periosteal bone has been thrown out on the adjacent portion of the shaft. F. P. C. 252. Presented by Professor John Thomson. 3. 365. Gunshot Fracture of the Tibia.— Portion of the shaft of a tibia — macerated, showing the above. The patient was wounded at Waterloo. The features of this specimen are essentially similar to those of the foregoing, there being indications of a septic compound fracture. Necrosis has begun at the seat of fracture, and new periosteal bone has been thrown out on the adjacent portion of the shaft. F. P. C. 251. Presented hy Professor John Thomson. 174 , Injuries of Bone. 3.366. United Gunshot Fracture of the Tibia.— Left tibia and fibula — macerated, showing the above. The man was wounded in the American War (of Independence) and died in the Middlesex Hospital." The lower end of the upper fragment of the tibia has been tilted outwards and backwards. There is much callus at the seat of injury, and a bar of new bone unites the fibula to the tibia. There is considerable irregularity of the head of the fibula. B. C. XVII. 34. 3. 367. Old-standing" Gunshot Fracture of the Fibula, followed by Tuberculosis. — Lower half of a left tibia and fibula, with the foot partially macerated and dried, to show the above. " The leg at last fell into the state of a scrofulous joint, and was amputated." The fibula has evidently been broken two or three inches above the ankle, and has been united by a bar of new bone. The front of the lower fragment is somewhat opened out and carious. The shafts of the tibia and fibula above the seat of fracture show very little deposit of new bone. B. C. XVII. 35. 3. 368. Old-standing" Gunshot Fracture of the Fibula, followed by Tuberculosis.— Oil painting by Sir Charles Bell of the leg and foot from which the foregoing specimen was taken. The ulcer was considered scrofulous. There was also con- siderable swelling of the leg in the neighbourhood. B. C. XVII. 36. 3. 369. Gunshot Fracture of the Tarsus. — Astragalus, greater part of OS calcis, and portion of the first metatarsal bone — macerated, showing the above. Gunshot Fractures. 175 A distorted bullet is mounted along with the fragments. A portion of the outer shell of the os calcis has been torn off. B. C. XVII. 40. 3. 370. Old-standing" Gunshot Injury of the Tarsus.— Irregular mass of bone, representing a right cuboid and other tarsal bones, now almost unrecognisable — macerated, to show the above. The cuboid in front is easily recognisable. Behind it is au irregular mass, apparently to a large extent of new formation. Probably the greater part of the bone behind the cuboid has been newly formed from the periosteum of the os calcis, parts of which can still be recognised. A piece of lead is firmly embedded in the under surface of the new mass. B. C. XVII. 60. 3. 371. Gunshot Fracture of the Sternum. — Piece of bone, apparently chiefly of new formation, said to be an exfoliation after a gunshot wound of the sternum. B. C. xvii. 48. 3. 372. Gunshot Injury of Bone.— Two leaden bullets show- ing the diversity of forms which balls take after hitting a bone ; also a macerated portion of detached bone with an osseous crust upon it. B. C. xvii. 49. 3. 373. Gunshot Injury of Bone.— Musket balls altered in shape, found in wounds. These were extracted from wounds received at Waterloo. They are variously altered in shape by having struck bone. F. P. C. 264. Presented hy Professor John Thomson. 176 Injuries of Bone. 3. 374. Gunshot Injury of Bone. — "Portions of a bullet found in John Bevet's femur. See Case iii." (?) G. C. 3556. 3. 375. Gunshot Injury of Bone. — Small shot, distorted in shape, taken from the knee of Robert Robb, Royal Infirmary, 23rd October 1824. F. P. C. 261. 3. 376. Gunshot Wounds. — One leaden, and four larger iron balls, and one large irregular piece of iron, found in wounds. B. C. XVII. 57. 3. 377. Gunshot Injury of the Face by Explosion.— Cast of the breech of a gun. The original was removed from the superior maxilla of William Roberts, of Powgus, Newfoundland, by Dr Fraseron the 19th of June 1856. G. C. 2403. Presented by Professor Miller, Nov. 1856. FROM THE CRIMEA. 3. 378. Comminuted Gunshot Fracture of the Shaft of the Femur — Lower two-thirds of a left femur — macerated, to show the above. Loose fragments are Avired in position. "The femur is much comminuted between the lower and middle thirds, callus has been thrown out, enclosing large pieces of dead bone and part of the ball. The history of the case was as follows : — " J. B. , pet. 34, a private in the Grenadier Guards, was wounded at the battle of Alma, on tlie 20th September 1 854. He was in the act of advanc- inecimens of their Tcind, illustrating the form of injuries liToduced by rifle bullets in the late American War. 8. 379. Gunshot Fracture of the Shaft of a Femur.— Lower half of aright femur comminuted above the condyles — macerated, the fragments wired together. There is an oval aperture on the front, about three inches above the level of the condyles, with its edges somewhat bevelled internally and sharp externally. On the posterior aspect is another irregular aperture, at a higher level, and further out than the other, and with its margins bevelled externally. The bone in the neighbourhood is broken up into numerous M 178 Injuries of Bone. fragments, larger in front and on the sides, and smaller on the back. There are only one or two fissures extending beyond the comminuted portion, and these only for about one inch. Probably the musket ball struck the femur obliquely, and passed from the front upwards and outwards, carrying some of the bone before it. G. C. 3423. Presented by Surgeon-General Billings, U.S.A. 3. 380. Gunshot Fracture of the Femur, involving the Knee-joint. — Lower end of a right femur, severely injured. Just above the condyles on the back the cancellous tissue is wanting, apparently having been transversely ploughed up by the bullet. The bone is broken across a little above this level, and a large piece has been driven out of the inner side. The inner condyle has been detached. On the outer side, the lower part of the aperture is somewhat circular, and its margins are indented. The injury has evidently been caused by a musket-ball striking the outer side about one inch above the outer condyle. G. C. 3424. Presented by SnTgeon-General Billings, U.S.A. 3. 381. Gunshot Fracture of the Femur, involving- the Knee-joint. — Bones forming a left knee-joint — macerated, showing the above. The bone has been irregularly ploughed up and broken across, just above the articular surface. The outer shell of the cancellous tissue has been split and turned aside at one place, and the upper margin of the patella has been injured. G. C. 3425. Presented by Surgeon-General Billings, U.S.A. 3. 382. Bullet lodged in the Outer Condyle of the Femur. — Bones forming a right knee-joint — macerated, showing the bullet in position. Gunshot Fractures of the Tibia. 179 The bullet still preserves its conical shape, although it has been rendered in-egular by impact against the bone. It has forced itself partly into the outer condyle, and has partly split it off. The bullet, however, has had but a shallow bed, and, except for the surrounding soft parts, must have been loose. It is now held in place by a wire. G. C. 3426. Presented by Surgeon-General Billings, U.S.A. 3. 383. Gunshot Fracture of the Upper End of the Tibia and Fibula. — Upper end of a right tibia and corresponding part of the fibula, except the head, which is wanting. The specimen is macerated, and the fragments wired together, to show the above. There is great comminution of the tibia, and loss of sub- stance. An irregular hole, larger on the outer side, is seen on either side of the tibia, below the articular surface. The sur- rounding bone is comminuted into numerous fragments, and the knee-joint has been extensively involved. G. C. 3427. Presented by Surgeon-General Billings, U.S.A. 3. 384. Lodging of a Bullet in the Head of the Tibia after Penetration. — Upper end of a left tibia and fibula — macerated, showing changes from the above injury. A conical bullet is seen with its tip just emerging at the back of the inner tuberosity, 'having passed obliquely backwards from the front and outer side. There is considerable loss of substance in the track of the bullet, which has split the bone, and, at the back, wedged the portions aside. The splitting extends for about four and a half inches down the shaft. Some cloth surrounds the back of the bullet, having evidently been carried in with it. G. C. 3428. Presented by Surgeon-General Billings, U.S.A. 180 Injuries of Bone. 3. 385. Gunshot Fracture of the Tuberosities of the Tibia. — Upper half of a right tibia — macerated, to show the effects of the above injury and the commencement of repair. There is an irregular aperture below the front of the inner tuberosity, and another at a higher level, below the back of the outer tuberosity. The front aperture is the larger, but pieces of bone split off near the back aperture have been reuniting in their original position, thus making it seem unduly small. The bone is fissured into the knee-joint, and for about six inches down the shaft. There is new periosteal bone round the seat of injury and partly filling up the fissures. These changes must have occupied several weeks. G. C. 3429. Presented hy Surgeon-General Billings, U.S.A. 3. 386. Gunshot Fracture throug-h the Tuberosity of the Tibia. — Upper end of a left tibia — macerated. The injury i& similar to the last. The bullet has struck the front of the outer tuberosity and has emerged at the back of the inner tuberosity, at a higher level. There is a small somewhat circular aperture in front and one larger and more irregular behind. A piece of bone split off at the back has been attached by a wire. The- splitting passed into the knee-joint and shaft. Some new bone has formed round the seat of injury. G. C. 3430. Presented by Surgeon-General Billings, U.S.A. 3. 387. Gunshot Fracture of the Upper End of the Shaft of a Tibia. — Upper two-thirds of a right tibia and fibula — macerated, with fragments wired together. On the inner side of the shaft of the tibia, three inches- be! ow the tuberosity, there is a somewhat circular aperture, with its margins bevelled towards the interior of the bone. On the outer side a large irregular gap is seen, with its margins in places bevelled outwards. The bone surrounding these aper- Gunshot Fractures of the Tibia. 181 tures is greatly comminuted, especially at the back and outer side, but there is comparatively little splitting upwards, and none down-wards beyond the fragments. The fibula is broken a little above the point where the bullet struck the tibia, and may have been secondary to the fracture of the tibia. Some new periosteal bone has formed at and near the injured places. The bullet evidently struck the tibia from the outer side, and carried away bone before it on the inside. G. C. 3431. Presented by Surgeon-General Billixgs, U.S.A. 3. 388. Gunshot Fracture of the Lower End of the Tibia. — Lower end of a left tibia and fibula — macerated, with the fragments wired together. There is an irregular aperture in front of the tibia two inches above the articular surface. The margins are bevelled towards the inside. At the back of the bone opposite there is another aperture, somewhat smaller and more irregular than that in front, with its margins bevelled externally. The inner malleolus and half of the articular surface is split off from the rest of the bone, and the fissures extend upwards into the shaft for some inches above the seat of injury. The bullet has evidently struck the leg from the front and outer side, and has passed backwards and slightly downwards. G. C. 3432. Presented by Surgeon-General Billings, U.S.A. 3. 389. Gunshot Fracture of the Bones forming" the Ankle-Joint. — Lower ends of a right tibia and fibula, with the astragalus and os calcis — macerated, showing the effects of gunshot injury at the back of the ankle. The outer malleolus has been carried entirely away, and the adjacent parts of the astragalus and tibia are ploughed up. The ball has apparently passed obliquely from before back- wards. G. C. 3433. Presented by Surgeon-General Billings, U.S.A. 182 Injuries of Bone. 3. 390. Gunshot Shattering" of Foot.— Bones of a left foot — partially macerated and dried, and showing great laceration of the tarsus and lower end of the tibia. The internal cuneiform bone, scaphoid, and astragalus are broken up into unrecognisable fragments, while the lower end of the tibia and sustentaculum tali of the os calcis have been severely comminuted. The other bones of the foot and the fibula have escaped. G. C. 3434. Presented by Surgeon-General Billings, U.S.A. COMPARATIVE PATHOLOGY OF FRACTURES. 3. 391. Process of Union after Fracture in the Bones of Birds. — Two humeri, also portions of a metatarsal bone and of the tibia and fibula of two chickens — macerated, after experi- mental fracture. No account is given of the details of the experiments, but the specimens all show development of callus round the broken ends. The uppermost specimen shows enlargement of the lower half of the bone. Both the humeri exhibit a closing of the medullary cavity in the upper fragment, and the three lower broken bones show necrosis at the seat of fracture, with much new bone formed round it. G. C. 206. 3. 392. United Fractures in the Bones of Birds.— Series of sections through united fractures of three bones, apparently femora, of fowls — macerated. The bones have united in bad position in each case, but the overlapping ends have been covered in, and the interval between the bones filled up by cancellous tissue. In the sections of the two lower fractures the original shell is distinguishable at the point of fracture, but in the uppermost fracture its two sections show the original shell to have become blended with the intervening cancellous tissue. G. C. 3528. Fractures in the Lovjer Animals. 183 3. 393. United Fracture of the Femur of a Domestic Fowl. — Right femur of a domestic fowl — macerated, showing the mode of union. The broken ends have overlapped greatly, and the lower fragment has been rotated outwards. A bridge of new bone unites the adjacent parts, and the medullary cavity in each case has been covered in by new bone. G. C. 1540. Presented by Dr Gairdnee. 3. 394. United Fracture of the Tibia of a Pheasant.— Right and left tibia and fibula of a pheasant — macerated, showing a united fracture of the right. The bone is shortened by half an inch, and there is a great deal of thickening round the seat of fracture. G. C. 3256. Presented by Chaeles W. Cathcart, F.R.C.S.E. 3. 395. Ununited Fracture of the Neck of a Fox's Femur. Left femur of a fox — macerated, showing changes following the above injury. The neck of the bone has entirely disappeared, but at the seat of fracture much irregular new bone has been thrown out, and partly fills the hollow of the great trochanter. The adjacent surfaces of the remains of the head and of the root of the neck have been eburnated by friction. The remains of the head, which was loose, and is now attached to the bone by a wire, shows great irregularity of the articular surface. These changes resemble those found in arthritis deformans. G. C. 1754. Presented by Robert Hood, M.D., October 1835. 3. 396. Compound Fracture of the Femur of a Rabbit.— Left femur, apparently of a rabbit — macerated, showing changes after the above injury. At the seat of fracture some of the original shaft is shown, 184 Injuries of Bone. and has apparently necrosed, for it is in process of separation. Near the necrosed portions there is much thickening by develop- ment of new bone in the extremity of the lower piece, even down to the knee-joint. G. C. 3529. 3. 397. United Fracture of the Femur of a Small Quad- ruped.— Right and left femur of a small quadruped — macerated. The right bone is thickened over its whole extent, and the sharp ledge formed in its upper third is evidently due to fracture at that point. G. C. 3530. 3. 398. United Fracture of the Spine of a Cat.— Part of the spine of a cat — macerated. The specimen shows great alteration from the above injury. At one place the bodies of the vertebrae have been completely dislocated, and their ends overlap. Much new bone has been thrown out in the neighbourhood. The spinal cord must have been completely torn across. G, C. 3531. Fresented by Dr Abercromby. 3. 399. Lodging- of a Bullet in the Femur of a Deer.— Lower end of the right femur of a red deer — macerated, shoAv- ing a round bullet, and the condition of the surrounding bone. From the fact that round bullets had been disused for many years before the animal was killed, also from the appear- ance of the parts, the bullet must have lain in its position for a long time. Except for the original injury, the bullet must have caused the animal very little inconvenience. There is some irregularity of bone in the neighbourhood, but no appearance of any chronic irritation. G. C. 3079. Fresented by Charles M'Hardie, Gillie, Braemar. Joints of the Upper Limb. 185 SERIES 4. STRUCTURE OF JOINTS. 4. 1 . SternO-ClaviCUlaP Joint. — Dissection illustrating the struc- ture of the above — in spirit. G. C. 3562. 4. 2. Ligaments of the Outer End of the Clavicle, and of the Shoulder-Joint. — Dissection illustrating the structure of the above — in spirit. B. C. ii. N. 2. 4. 3. Shoulder-Joint. — Dissection of a shoulder-joint in which the synovial cavity has been distended with paraffin coloured blue — in spirit. G. C. 3563. 4. 4. Elbow- Joint. — Dissection of an injected elbow-joint, illustra- ting the lateral and anterior ligaments — in spirit. B. C. II. N. 3. 4. 5. Elbow-Joint. — Dissection illustrating the structure of the above — in spirit. G. C. 3564. 4, 6. Lower RadiO-Ulnar Joint.— Dissection to show the tri- 186 Structure of Joints. angular fibro-cartilage between the lower ends of the radius and ulna — in spirit. B. C. ii. N. 4. 4. 7. Carpal Joints. — Dissection of an injected preparation, showing the articular surfaces and some of the ligaments of the carpus. B. C. ii. N. 5. 4. 8. Joints of the Hand. — Dissection illustrating the joints of the wrist and carpus. G. C. 3565. 4. 9. Joints of the Fingers. — Dissection illustrating the above, —in spirit. G. C. 3566. 4. 10. Ligaments of the Thumb.— Dissection illustrating the lateral ligaments of the joints of the thumb. B. C. ii. N. 8. 4. 11. Ligaments of the Pelvis. — Dissection illustrating the above — in spirit. G. C. 3567. 4. 12. Ligaments of the Pelvis. — Dissection illustrating the above — in spirit. G. C. 3568. 4. 13. Ligaments of the Pelvis.— Dissection illustrating the above — in spirit. G. C. 3569. 4. 14. Symphysis Pubis. — Two sections of the symphysis pubis, to illustrate the above — in spirit. B. C. ii. N. 12. Joints of the Lower Liml. 187 4. 15. Hip-Joint.— Acetabulum, dissected to show the cotyloid and transverse ligaments. B. C. ii. N. 14. 4. 16. Hip-Joint. — Dissection of the hip-joint — injected, showing the ligamentum teres and the ligaments on the back and upper parts, the front of the capsule having been removed — in spirit. B. C. II. N. 13. 4. 17. Hip- Joint. — Preparation of the ilium and adjacent part' of the femur. The bones are macerated, and the ligaments dried and painted. These ligaments are, particularly, the "ischio-femoral band," described by Dr Struthers (" Edinburgh Medical Journal," 1858), passing spirally at the back from the ischium to the fore-part of the great trochanter, and so placed as to check rotation inwards during flexion. The ligamentum teres, exposed by Dr Struthers' method, is seen not to be tense, and to lie out of its functional groove, in the erect posture. G. C. 3467. Presented by Professor Struthers. 4. 18. Hip-Joint. — Dissection illustrating the structure of tl.ie above. G. C. 3570. 4. 19. Knee-Joint. — Dissection of an injected preparation, espec- ially illustrating the sub-patellar pad of fat and ligamentum mucosum, as well as the lateral and crucial ligaments from behind. B. C. II. N. 19. 4. 20. Knee-Joint. — Dissection of a left knee-joint, to show the attachment of the crucial ligaments — in spirit. B. C. II. K 17. 188 Structure of Joints. 4. 21. Knee- Joint. — Dissection of a left knee-joint, to show the position of the semi-lunar cartilages in relation to the crucial ligaments — in spirit. The patella has been turned downwards, and the coronary and transverse ligaments have been dissected away, and only portions of the lateral ligaments left. B. C. II. N. 18. 4. 22. Knee-Joint. — Semi-lunar cartilages of a left knee-joint, removed along with the portion of the tibia to which their extremities are attached. B. C. n. N". 20. 4. 23. Knee-Joint. — Dissection of a knee-joint, to show the attach- ment of parts to the tibia. G. C. 3571. 4. 24. Knee-Joint. — Dissection of a knee-joint, to show the. relations of the synovial membrane. G. C. 3572. 4« 25. Knee-Joint. — Patella, with the tendon of the quadriceps extensor, and ligamentum patellae — in spirit. B. C. n. N. 15. 4. 26. Lower Tibio-fibular Articulation.— Lower end of tibia and fibula to show the interosseous ligaments — in spirit. On the outer and front part of the tibial articular surface there is a mark as if of an old fracture. B. C. ii. N". 21. 4. 27. Ankle-Joint. — Dissection of the lateral ligaments of the ankle-joint — in spirit. G. C. 3573. Joints of the Lower Limh. 189 4. 28. Joints of the Ankle and Foot. — Dissection to illustrate the synovial cavities of the ankle and foot — in spirit. G. C. 3574, 4. 29. Tarsal Joints. — Dissection to show the chief tarsal articu- lations— in spirit. G. C. 3575. 4. 30. Tarsal Articular Surfaces.— Dissection of the bones of the foot, to show the articular surfaces — in spirit. B. C. II. K 22. 4. 31. Articulations of the Great Toe.— Dissection of the bones of the great toe of a foot which had been injected, to illustrate chiefly the articular surfaces — in spirit. B. C. II. N. 23. 4. 32. Great Toe Joint. — Section of joint between the great toe and first phalanx, showing the relation of parts — in spirit. B. C. II. N. 24. 4. 33. Temporo-maxillary Articulation. — Preparations show- ing the inter-articular cartilage of the lower jaw — in spirit. B. C. II. N. 11. 4. 34. Temporo-maxillary Articulation.— Preparation illus- trating the ligaments of the above joint. G. C. 3576. 4. 35. OccipitO Alto-axial Joint. — Dissection illustrating the above — in spirit. G. C. 3577. 190 Structure of Joints. 4. 36. Alto-axial Joint. — Dissection illustrating the above — iu spirit. G. C. 3578. 4. 37. Inter- vertebral Joint. — Dissection showing some of the chief inter-vertebral ligaments. G. C. 3579. 4. 38. Inter-vertebral Substance.— Preparation of the inter- vertebral substance separated from the bone, showing the pulpy structure at the interior and the fibrous nature outside. B. C. II. N. 1. Dislocations of the Upper Limh. 191 SERIES 5. INJURIES OF JOINTS. DISLOCATIONS OF THE CLAVICLE. 5. 1. Forward Dislocation of the Sternal End of the Clavicle. — Cast in glue and glycerine of the front of the •chest of an adult, showing the above. The patient, an elderly workman, was hit on the back of the right shoulder by a passing truck and knocked down. Under chloroform the dislocation was partially reduced, but it was found impossible to retain the bone properly in its place. The patient left the Hospital, however, with a fairly useful arm. The projection of the sternal end of the right clavicle is well seen. G. C. 2858. Presented hy Qnx-R.i.Y.s W. Cathcart, F.R.C.S.E. DISLOCATIONS OF THE UPPER LIMB. 5. 2. Unreduced Sub-coracoid Dislocation of the Shoulder. — Left scapula — macerated,^ showing changes dependent on the above. The inner margin of the glenoid cavity has been worn away, and the adjacent bone is rough and irregular. These changes have most probably followed an old-standing sub- coracoid dislocation of the humerus. B. C. ii. M. 46. 5. 3. Unreduced Sub-coracoid Dislocation of the Shoulder. 192 Injuries of Joints. — Left scapula, with adjacent parts of clavicle and humerus — in spirit, showing the above. The inner margin of the glenoid cavity of the scapula is worn away, and the adjacent bone on the ventral surface is flat and smooth. The greater part of the articular surface of the humerus is irregular, and covered by fibrous material. At the back of the greater tuberosity, the bone has been smoothed down by friction against the scapula, and near it there is a projecting spur of bone. Portion of a strong fibrous capsule is seen on the inner side of the head of the humerus. The bone forming the infra-spinatus fossa has been fractured, and has united with great irregularity. B. C. ii. M. 44. 5. 4. Unreduced Sub-coraeoid Dislocation of the Shoulder. — Eight scapula and humerus — macerated, showing the above. The specimen is from the same patient as the last. Evidently on this side also there has been an unreduced dislocation. The original glenoid cavity is partly filled up by newly formed bone, and a new cavity has been formed inside, and below the level of the first one. The head of the humerus shows many alterations. The greater and lesser tuberosities have atrophied, and their surfaces pass insensibly into those of the shaft and head respectively. The articular surface of the head is irregular, and a mass of new bone has been thrown out at the outer and back part of the surgical neck. The surface of this new piece is porous, and the intervals between the small holes are at places eburnated. This condition resembles that often produced by arthritis deformans upon the head of the femur. B. C. ii. M. 45. 5. 5. Old-standing Sub-coracoid Dislocation of the Shoulder. — Right scapula, with adjacent portions of the humerus and clavicle, from a person aged 76 years. \ Dislocations of the Shoulder. 193 There is an unreduced sub-coracoid dislocation of the humerus, and the edge of the glenoid cavity has caused a depression upon the back of the anatomical neck. This part of the bone is elongated, so that the neck of this humerus almost resembles that of a femur. These changes may have been pro- duced by a splitting of the great tuberosity against the edge of the glenoid cavity at the time of the accident, and afterwards by absorption from pressure and some new formation. (See paper by Caird, "Edinburgh Medical Journal," 1886.) The original glenoid cavity is partially filled up, and an imperfect new one has been formed below the coracoid process, G. C. 3468. Presented by Professor Struthers, January 1893. 5. 6. Double Sub-eoracoid Dislocation of the Shoulder.— Plaster of Paris cast of the front of the chest and shoulders of an adult, showing the above. The dislocation on the right side -R-as recent, that on the left side was old-standing. It may be noted that the unreduced dislocations, Nos. 5. 3 and 5. 4 were also from one person. G. C. 2678. P)-ese7Ued by J . D. Gillespie, F.R.C.S.E. 5. 7. Old-standing- Sub-g-lenoid Dislocation of the Shoulders. — Plaster of Paris cast of the upper part of the chest and shoulders of an adult, showing the above. The appearances on the left side are characteristic of old- standing dislocation. G. C. 3306. 5. 8. Sub-spinous Dislocation of the Shoulder.— Right scapula and upper part of humerus, with the muscles partly dissected — in spirit, to show the above. 194 Injunes of Joints. The patient, a strong man, had fallen over a gi-eat height, and had received severe internal injuries, from which he died shortly after his admission into the Royal Infirmary. The deltoid has been thrown down to expose the region of the shoulder. The head of the humerus was displaced backwards into the infra-spinatus fossa, and is seen lying on the infra-spinatus muscle. The capsule of the shoulder-joint and the attachment of all the muscles to the two tuberosities, except a small portion of the teres minor, were completely torn off. The surrounding muscles and areolar tissue were infiltrated with blood. Prepared by G. Hardyman, M.B. G. C. 3580. Presented hy H. P. Miller, F.R.C.S.E. 5. 9. Forward Dislocation of the Head of the Radius. — Glue and glycerine cast of a fore-arm and part of an upper arm, showing the above. The bone had been dislocated some years before, and had never been reduced. The arm was, however, quite useful, except that flexion was limited. The cast shows the projection of the head of the radius, which occurred during flexion. G. C. 3202. Fresentecl hy Charles W. Cathcart, F.R.C.S.E. DISLOCATION OF THE HAND AND FINGEES. 5. 10. Backward Dislocation of the Second Metacarpal Bone. — Cast, in glue and glycerine, of a right hand, showing the above. The patient was a ticket -of-leave man. The accident occurred in the course of a fight. An attempt at reduction without chloroform failed, and the patient left the Infirmary before any further treatment could be tried. The cast shows the projection of the base of the bone at the carpus, and the sinking in of the head of the bone at the knuckle. G. C. 2867. Presented hj CvLk^-L^s W. Cathcart, F.R.C.S.E. Dislocations of the Lower Limb. 195 5. 11, Backward Dislocation of the Second Metacarpal Bone. — Cast, in glue and glycerine, of left hand of the above patient, as a contrast with the injured side. G. C. 2868. Fresented by Charles "W. Cathcart, F.R.C.S.E. 5. 12. Forward Dislocation of the First Phalanx of the Thumb, — Plaster of Paris cast of a right hand, showing the above. The cast was taken from the hand of a pugilist named Wood, but there exists no history as to how the accident occurred. B. C. ii. M. 61. DISLOCATIONS OF THE LOWER LIMB. 5. 13, Dislocation on to the Dorsum Ilii.— Plaster of Paris cast of a left innominate bone and upper end of the correspond- ing femur, showing the above. The head of the bone has lain on the dorsum ilii, just above the acetabulum. The femur has been greatly flexed and adducted. G. C. 3087. Copied by permission from a specimen in Professor Annandale's Museum. Fresented by Charles W. Cathcart, F.R.C.S.E. 5. 14, Unreduced Dislocation on to the Dorsum Ilii,— Portion of a left innominate bone and corresponding end of femur — muscles dissected ofif, in spirit — showing the above. The specimen was taken from a dissecting-room subject. The original acetabulum is nearly filled up by fibrous tissue, and just above it, on the dorsum ilii, depression has been formed by the head of the bone in its new position The greater part of the head and neck of the femur have disappeared, but the small trochanter is enlarged. 196 Injuries of Joints. A strong band of fibrous tissue unites the under surface of the remains of the neck of the femur with the upper part of the old acetabulum. B. C. ii. M. 13. 5. 15. Unreduced Thyroid Dislocation. — Plaster cast of a left innominate bone and upper end of the corresponding femur, showing the above. The head of the bone has formed for itself in the thyroid foramen a new socket, which has encroached upon the acetabulum. G. C. 1931. Presented by J. A. RoBErvTSON, F.R.C.S.E., 1838. DISLOCATION OF THE PATELLA. 5. 16. Outward Dislocation of the Patella.— Condyles of a left femur, with a greatly altered patella — macerated, showing the above. The condition has evidently been of many years' standing. The articular surfaces of the femur are irregular, and much new bone has been thrown out round the margins. The anterior surface of the patella is unchanged, but on the posterior or articular surface a large mass of new bone has been formed, and has adapted itself to its new position on the outer condyle withou^t adhering to it. Many of the changes seen on the articular surfaces of the femur resemble those found in arthritis deformans. B. C. n. M. 27. 5. 17. Vertical Dislocation of the Patella.— Plaster of Paris cast of a right knee, showing the above. The patella has been twisted, so as to rest upon its outer edge against the trochlear surface of the femur. G. C. 2477. Presented by C. Darutt, L.R.C.S.E. Dislocations of the Lower Limh. 197 DISLOCATION OF THE KNEE. 5. 18. Partial Outward Dislocation of the Knee.— Plaster cast of a right knee, showing the above. The skin Avas drawn very tightly over the inner condyle, and would have sloughed had reduction not been eflfected. The tibia and fibula have been displaced outwards and back-\vards. G. C. 3112. Fresented by Alexis Thomson, F.R.C.S.E. 5. 19. Compound Dislocation of the Knee. — Plaster cast of a right knee, showing the above. The ligament was torn, and the skin on the inner side ruptured so as to expose the interior of the knee-joint. The tibia and fibula have been displaced inwards and backwards. 5. 20. Partial Outward Dislocation of the Tibia and Fibula. — Glue and glycerine cast of a left knee, showing the above. Four years before, the patient, a young man, then aged 20, had struck his knee in trying to jump into a cart. Several ineffectual attempts had been made to reduce the defoi'mity. The joint subsequently became affected with tubercular disease, and shortly after the cast was taken the joint was successfully excised by Mr A. G. Culter. (See Series 7.) The cast shows a slight outward dislocation of the tibia, but the relation of the parts was masked by swelling of the synovial membrane. G. C. 2891. Presented hy Charles W. Cathcakt, F.R.C.S.E. DISLOCATION OF THE FOOT. 5. 21. Compound Sub-astragraloid Dislocation.— Right foot and lower part of leg, muscles and tendons dissected, to illustrate the above — in spirit. Amputation was performed through the leg. 198 Injuries of Joints. The tendons are not much displaced. The astragalus has pre- served its relation to the tibia and fibula, but has been torn from its attachments to the scaphoid and os calcis. The foot has been twisted inwards, so as to leave the head of the astragalus projecting on the outside. G. C. 1431. Presented by Benjamin Bell, F.R.C.S.E., 1827. 5. 22. Compound Sub-astragaloid Dislocation.— Plaster cast, coated with wax and painted, illustrating the condition of the foregoing specimen immediately after amputation. The head of the astragalus is seen protruding through the skin. G. C. 1432. Presented by Benjamin Bell, F.R.C.S.E., 1827. 5. 23. Compound Sub-astrag'aloid Dislocation. — Plaster cast, coated with wax and painted, illustrating the condition of the same specimen after removal of the skin, G. C. 1433, Presented by Benjamin Bell, F.R.C.S.E., 1827. 5. 24. Dislocation of the First Metatarsal Bone.— First metatarsal bone from the right side of a young person — macerated. The bone was forced out of its place by the tramp of a horse. The patient recovered from the injury, and the movements of the foot were afterwards unimpaired. The bone itself does not seem to have been injured. G. C. 1163. Presented by VroiessoY James Russell, F.R.C. S.E. Abnormalities of Bone. 199 SERIES 6. DISEASES OF BONE. L ABNORMALITIES IN GROWTH OR DEVELOPMENT. 6. 1. Abnormal Development of Skeleton.— Skeleton of an Anencephalic male foetus — macerated, showing the above. The cranial bones are imperfectly developed, and the vault of the skull is very shallow and quite deficient at the vertex. The parietal bones are feebly developed, while there is a large gap corresponding to the foramen magnum. There are six digits on each hand and foot, the extra one being super- numerary to the fifth in each case. In both hands the extra digit arises from the fifth metacarpal bone, which is unduly broad. A similar arrangement is seen on the left foot, but on the right foot the fifth metatarsal bone is double. The radius on each side is somewhat bent and flattened, and the tibiae are broad and somewhat bent. In other respects the skeleton seems well developed. G. C. 3494. Presented hy Alexis Thomson, F. E.. C. S. E, 1893. 6. 2. Abnormal Development of Skeleton. — Three photo- graphs of the above foetus, showing the appearances presented before dissection. The relative shortness of the lower limbs and their some- what inverted position should be noted. The bloated appear- ance of the features in the front and side views is clearly demon- strated, and in the profile view the relative smallness of the cranium and the protrusion of brain and membranes through the vertex is well shown, G. C. 3495. Presented hj A-LY.xifi Thomson, F.K.C.S.E., 1893. 200 Diseases of Bone. 6. 3. Imperfect Development of the Arch of the Atlas. — Atlas vertebra from an adult — macerated, illustrating the above. The bone seems well developed, except that the arch is incomplete on the right side, near its junction with the lateral mass. G. C. 992. 6. 4. Cervical Rib. — Eight first rib of an adult, with an extra rib fused to it — macerated. The first rib itself has a ridge for the attachment of the scalenus anticus muscle, with a groove in front and behind it. The ridge separating these two grooves runs in the direction of the extra rib. The extra rib has a well-marked head, neck, and tubercule, with about one inch of a body, before it blends with the first rib. The place of junction is much flattened, and on the inner side is prolonged into a flattened spike, directed forwards and inwards. G. C. 3533. II. CHANGES PEODUCED BY CONDITIONS AFFECTING THE NUTRITION OF BONE. A. Changes in old age. 6. 5. Chang-e in the Humerus from Old Ag-e. — Upper end of a right humerus, in section — macerated, to show the above. The bone was very greasy, and was with difficulty cleaned of fat and oil. The compact tissue of the shaft is diminished in thickness. There is considerable atrophy of the cancellous tissue at the upper end, and the whole texture of the bone is lighter and more friable than in the adult condition. Tlie changes in this bone may be taken as characteristic of those found in the long bones of old people, when senile decay has; appeared. G. C. 3334, Fresented by MACDO'i^A.LJ) Bkown, F.R.C.S.E. Senile Changes in Bone. 201 6. 6. Senile Osteo-malacia of the Femur.— Longitudinal sections of the left femur of an old -vvonian, showing the above. The patient was bed-ridden in the workhouse, and all her bones showed a similar change. The bone is much lighter and more fragile than usual, and in places at either end could easily be marked with the finger- nail. The outer wall of bone has been reduced to a mere shell, except at the upper end of the shaft, and there the bone tissue, although thicker than elsewhere, is opened out almost into cancellated tissue. The cancellated tissue at the extremities is extremely light and delicate, and in places has disappeared. On the surface the marks of muscular attachments are less prominent than usual, and in places the surface is porous. When fresh, the interior of the bone was filled by a reddish- brown jelly-like material which had replaced the marrow, except at the middle of the shaft. It was not greasy. The bone was easily macerated, and is quite dry, except at the lower end, where it is slightly oily. The angle which the neck forms with the shaft does not seem altered, possibly because the patient was bed-ridden some time before her death. G. C. 3222. Presented by Q-H.k\\hY.H W. Cathcart, F.R.C.S.E., 1891. 6. 7. Senile Osteo-malacia of the Tibia.— Sections of the left tibia from the same patient — macerated, to show the above. The bone shows characteristic changes, in all respects similar to those seen in the previous specimen. G. C. 3223. Presented by CuKVih-ES, W. Cathcart, F.R.C.S.E., 1891. 6. 8. Senile Osteo-malacia of the Sacrum and Coccyx.— Sacrum, coccyx, and last two lumbar vertebrae, from the same patient — macerated, to show the above. The lower part of the sacrum is bent sharply forwards^ at about a right angle to the rest of the bone. 202 Diseases of Bone. The cancellated tissue is very delicate and friable, so much so that the ossa innominata came to pieces during maceration. The pelvis was peaked as in osteo-malacia, but there was none of the greasiness found in that condition. G. C. 3228. Presented hy Charles W. Cathcart, F.R.C.S.E. 6. 9. Senile Osteo-malacia of the Scapula— Right scapula from the same patient — macerated, to show the above. The spine and superior angle were broken in removing the soft parts. This bone shows characteristics similar to those seen in the other bones of this subject, and the greater part of the venter is as thin as paper. G. C. 3227. Presented hy Cka.^l'&h W. Cathcart, r.KC.S.E. 6. 10. Senile Osteo-malacia of the Clavicle. — Left clavicle from the same patient — macerated, to show the above. Like the other bones from this subject, it is light and dry, and deficient in muscular markings. G. C. 3226. Presented by Charles W. Cathcart, F.K.C.S.E. B, Changes from various local conditions aj^ecting the nutrition of hone. 6. 11. Deg-eneration of the Os Calcis from Disease of other Bones of the Foot. — Section of a right OS calcis — macerated, to illustrate the above condition. The bone remains saturated with oil, notwithstanding efforts to remove it. The patient had suffered for many years from tuberculosis of the foot, affecting chiefly the soft parts, but extending to the tarsal and meta- tarsal bones at the outer side. The os calcis was not affected by the disease, and the changes seen were secondary to the real disease and quite distinct from it. The bone tissue is very light, and is reduced to a transparent film in many places. G. C. 3310. Presented by Charles W. Cathcart, F.R.C.S.E. Atrophy of Bone. 203 6. 12. Atrophy of the Tibia and Fibula, following- Anchylosis of the Knee-joint from Disease.— Left tibia and fibula and lower end of corresponding femur and patella — macerated, to show the above. A portion has been removed from the head of the tibia to show the condition of the cancellous tissue. The bones are very greasy, and were made only tolerably clean after having been several times boiled in soda solution. The patient had suffered from knee-joint disease, and many years before amputation the limb had become anchylosed in a flexed position. It was removed because it was in the way. The shafts of both bones are diminished in size, and are bent slightly backwards. The compact tissue, however, is strong, and the bones are apparently not lightened in proportion to their diminished size. The section through the cancellous tissue shows it to be stronger and firmer in the epiphyses than in the upper part of the shaft. The patella has been anchylosed by bone to the femur. The articular surfaces of the femur and tibia are irregular, but without any sign of existing active disease. The changes in these bones may be attributed partly to disuse and partly to other results of the previous knee-joint disease. G. C. 3554. Frescnted by A. G. Milleu, F.R.C.S.E. 6. 13. Atrophy of the Bones of the Foot from Disuse — Section of the bones of a right foot — macerated, to show the above. The patient had been unable to walk properly for some years, owing to the gradual enlargement of a central sarcoma of the fibula, for which the leg was eventually amputated. The texture of the bones is light and greasy. G. C. 3235. Presented by P. H. Watson, F.R.C.S.E. 6. 14. Atrophy of the Bones of Leg- and Foot from Disuse, 204 Diseases of Bone. following" Anchylosis from Rheumatism.— Bones of a right leg and foot, soft parts cleaned off — dried, to show the above. D. W., aged 18 years, was troubled with pains in the joints of his right foot at the age of 10. Shortly after this he was confined to bed for three months with a "fever" (probably rheumatic), which affected all the joints of his body. Two years later he had a relapse of the same fever, with implication of most of his joints, especially those of the right foot. Since then he has had several similar attacks, and, with the exception of the sterno-clavicular and temporo-maxillary, all the joints of liis body have become deformed and more or less rigid. He has thus been completely crippled and helpless, even in bed. The right knee was excised on 10th May, but as the operation was unsuccessful. Professor Annandale performed amputation above the knee on 24th July. The muscles of the leg, although greatly diminished in bulk, were of a fairly good colour. The periosteum stripped off very easily. The shafts of the tibia and fibula are much reduced in thickness, and the muscular markings are slight. The compact tissue is hard, but the cancellous tissue at the articular ends of the long bones and in the tarsal bones is extremely soft and fatty, and is surrounded by a scale of bone so thin and soft that it yields to the slightest pressure, and can be cut with the finger-nail. The joints of the ankle and tarsus are all anchylosed by bone, as are also those of the metatarsus, except that of the first metatarsal bone. The joint between the first and second phalanges of the great toe is anchy- losed, but all the other phalangeal joints have a certain amount of movement. G. C. 3581. Presented by Professor T. Annandale, F.R.C.S.E. 6. 15. Atrophy and Alteration in the Bones of the Foot, following" Injury. — Section of the bones of a right foot — macerated, showing the above. The patient was a middle-aged man. Early in life his foot had been injured, and gi-eat distortion resulted (see G. C. 2818). The skin had been greatly destroyed, and an ulcer which appeared on the heel broke out from time to time, and caused so much inconvenience that on account of it the foot was at last amputated. Atrophy of Bone. 205 The metatarsals are extremely thin, and are ossified together at their bases. The three cuneiforms and the scaphoid are also ossified together. The os calcis and the cuboid are widely separated. The cancellated tissue is very light, and in many places has disappeared. The bones were fairly easily cleared of fat. G. C. 2820. Presented by P. H. Maclaren, F.R.C.S.E. For other examples of atrophy from disuse, see "Stumps," series 11. For atrophy from continuous pressure, see series of General Pathology. 6. 16. Changes in Bone from Peripheral Nerve Lesion.— Specimen wanted. C. Changes from affections of the central nervous system. 6. 1 7. Alterations in Skeleton in a Case of Paralysis and Idiocy. — Skeleton of a woman, showing the above. The following description has been kindly furnished by the donor. " This specimen was obtained from the body of a woman aged 30, who died in the Norfolk County Asylum in 1891. Of a neurotic family, she was apparently healthy and well-formed at birth. When she was a year old, on attempting to stand, the weakness of the right arm and leg were noticed. The weakness increased, and the affected members became drawn up. She never walked. The recumbent position was adopted, and maintained from infancy till her death. She never moved the right arm or leg. She could move the head and grasp objects with the left hand. She suffered from convulsive fits from the age of 3 till the age of 26. She was a complete idiot." "The skull is typically micro-cephalic; it is also asymme- trical, the right half of the cranial box being greater in its dimensions and more convexly arched than the left. This assymmetry is the result of a lesion in early life of the left cerebral hemisphere of the brain, whereby the growth of the latter was interfered with." The bones of the trunk and extremities present features which are to be etiologically associated with a right-sided 206 Diseases of Bone. hemiplegia occurring in infancy, together with uninterrupted recumbency in bed for nearly thirty years. Those features specially connected with the hemiplegia show themselves, especially in the bones of the right arm and leg, and to a very much less extent in the trunk ; those features resulting from the recumbency and disuse are superadded to the former on the right side, but are also present in those of the left. In the trunk there is no apparent asymmetry apart from the scoliosis. Those on the paralysed side do not suffer by comparison with those on the side which retained the power of movement. The spinal column exhibits a type of curvature seldom met with, and in all probability only developed under condi- tions present in this case, i.e. paralysis of one side plus recum- bency. That little movement took place during life is evidenced by the bony union of certain of the laminge. The thorax has altered during the preparation of the specimen ; it was scarcely, if at all, involved in the scoliosis ; it was Avell formed, beyond a moderate flattening from before backwards. The pelvis, of the female type, is most notably wasted and thinned ; its diameters considerably altered. The bones of the extremities are on both sides small, thin, and light, deficient in ridges and marks for muscular attachment, present a fairly developed cortical layer in the shafts of the long bones ; the medulla and spongiosa very small in amount. The articular ends of the long bones and the short bones (e.g. tarsus) have but a thin and imperfect cortex, capable of being indented Avith the finger-nail. The ends of the long bones also present alterations resulting from the deformities to be presently described. Those on the right (or paralysed) side not only present the above features in a greater degree, but show evidences of the nerve lesion. They are distinctly shorter. This, as shown by measurement, varies in the different bones. It is most pro- nounced in the following bones, and in the order given : — humerus, femur, fibula, radius, ulna, tibia, clavicle. It is Atrophy of Bone. 207 absent in the scapula, metacarpals, metatarsals, and phalanges. The lones on the right side are also less in girth than those on the left. The changes in the ends of the bones, resulting from the deformities acquired in early life, are met with both on the right and on the left side, though much more pronounced in these of the former or paralysed side. They reach their acme in the lower extremities. The right hip-joint presents a complete dorsal dislocation of the head of the femur, with corresponding changes in the articular surfaces ; at the left side the dislocation is only partial. The right knee-joint is flexed to such a degree that the articular surfaces of the condyles are not in contact with the tibia; the facets of the latter are in contact with the superior aspect of the posterior extremities of either condyle. On the left side the flexion is less pronounced and the leg is rotated outwards. The right ankle-joint was acutely^flexed, remarkable — seeing that the toes of paralysed limbs are usually pointed : the superior surface of the neck of the astragalus articulated with the anterior aspect of the shaft of the tibia. On the left side the toes were pointed. In the upper extremities there are no evidences in the articular ends of the bones of the large joints of the contracture deformities on the right side, corresponding to those in the lower extremity. The articular surfaces remain in contact with each other, and are covered with hyaline cartilage. The hand, however, on the right side, preserved in its original conditions, presents the usual features of hemiplegic contracture. The brain. — See nervous system. (For a more minute description of the above skeleton, see the description by Dr Alexis Thomson in Journ. Anat. Phys.) G. C. 3496. Preimred and frtsentcd by Alexis Thomson, F.R.C.S.E. 6. 18. Alterations in Skeleton in a Case of Paralysis 208 Diseases of Bone, and Idiocy. — Photograph of the anterior aspect of the patient from whom the foregoing specimen was taken, showing the condition immediately after death. G. C. 3498. Presented hy Alexis Thomson, F.R.C.S.E, 6. 19. Alterations in Skeleton in a Case of Paralysis and Idiocy. — Photograph of the posterior aspect of the above patient, showing the condition immediately after death. G. C. 3498. Presented by Alexis Thomson, F.R.C.S.E. 6. 20. Atrophy of the Bones of the Leg" and Foot, from Infantile Paralysis. — Bones of the foot and lower two-thirds of tibia and fibula — partially macerated and cleaned, to show the above. The limb was soaked in Miiller's fluid, which has turned the bones green. The patient had been affected by infantile paralysis. In conse- quence, this leg and foot did not grow in proportion to the other one, and became useless. It was therefore amputated. The bones are both somewhat bent outwards, as in 'No. 6. 12. The shafts of the tibia and fibula are thin, and the usual ridges are wanting. The compact tissue, however, is not atrophied in proportion to the diminished size. The bones of the foot are light and very greasy. G. C. 3555. Presented by Alexis Thomson, 1893.']! 6.21. Alterations in Bone [due to Locomotor-ataxia. — Specimen wanted, D. Alterations due to conditions apparently constitutional, hut more or less obscure. (a.) HicJcets. 6. 22. Rickets in the Tibia of a Child.— Section of the right Rickets. 209 leg and foot of a child — injected, and in spirit, to show the above. The child was about eight years of age. The leg was amputated for tubercular disease of the knee-joint. The tibia is curved forwards. There is increased vas- cularity of the periosteum in the concavity of the arch,, especially at its lower end. At the centre of the concavity the cancellous tissue is becoming condensed. Otherwise the bone shows no marked change. G. C. 3199. Presented by A. G. Miller, F.R.C.S.E. 6. 23. Rickety Enlargrement of the Radius and Ulna- Cast — in glue and glycerine — of part of the left forearm and hand of a child, showing the above. The enlargement of the lower end of the radius and ulna is unusually well marked. Both sides were alike. G. C. 3245, Presented iy Charles W. Cathcakt, F.R.C.S.E. 6. 24. Rickety Enlargement at the Ends of the Ribs. — Sternum, costal cartilages, and anterior ends of seven upper ribs of a child aged two years, showing the above. The enlargement at the sternal ends of the ribs, known as. the "Rickety Rosary," is very well shown. G. C. 2560. Presented by R. Blair Cunynghame, F.R.C.S.E. 6. 25. Skeleton affected by Rickets.— Skeleton of a woman — showing the above — macerated. She died in child-bed. The bones are greatly altered, and the total height of the skeleton is 31| inches, measuring from the top of the skull tf> the heel. The skull is well formed, but on section it is seen to be thickened, especially on the roof. The thickened bone is 210 Diseases of Bone. spongy in character, and seems to occupy chiefly the middle and outer tables. Upper Limbs.— The clavicles are thin, and their curves are somewhat exaggerated. Scapulae. — The left scapula is small and thin, but otherwise normal in shape. The right is bent, so as to be concave forwards, but is otherwise unchanged. Owing to spinal curvature, it is placed higher than the left one. Humeri. — The humeri are each 8| inches in length, and have an outward bend at the deltoid attachment, where also a special ridge is developed. The outer lip of the bicepital groove is very prominent. The heads of the bones are flattened from above downwards. The condyles at the elbow are unusually prominent. Forearms. — The bones of the forearms are thin and somewhat irregular in shape, with prominent ridges and enlarge- ment of the lower ends of radii. The bones of the hands show no particular change. Spinal Column. — The spinal column presents an exaggerated degree of lateral curvature, convex to the right in the dorsal region, and to the left in the lumbar, with the usual rotation of the bodies of the vertebrae towards the convexity. Thorax. — The thorax presents the usual characters following ujDon lateral curvature, viz. on the right or convex side the angles of the ribs are exaggerated behind, and the ribs themselves seem unusually broad, while the curve is somewhat flattened in front ; on the left or concave side the ribs are compressed together and narrowed at the concavity, their angles being flattened at the back and their curvature increased in front. Sternum. — The body of the sternum is oblique to the manubrium sterni. Pelvis. — The pelvis is altered partly by rickets and partly by lateral curvature. The bones are thin and light. The alse of the ilium are ill developed and bent forward, somewhat like the osteo-malacian pelvis. The brim of the pelvis is contracted chiefly on the left side, where the acetabulum has been crushed up towards the sacrum. Lower Limbs. — Femora. — The femora are very short, measuring from the top of the great trochanters to their lower end only about 9 inches. They are curved forwards and Rickets, 211 outwards, are rotated outwards, and are flattened and enlarged at their lower ends. Tibae and Fibulse. — The tibiae and fibulae are bent almost completely double, so that the knees must have touched the outside of the foot during life. The bones of the feet are comparatively unaltered. B. C. I. 3. M. 24. 6. 26. Skeleton affected by Rickets.— Skeleton of a rickety woman (Christie Moore) showing alterations, chiefly in the limbs and pelvis. "She was the little woman, with rather a good face, and a great deal of impudence, who generally stood at the Infirmary gate to talk to the students. She went with great velocity on her crutches. She had no motion in her legs separately, they being twisted together curiously. This made it the more extraordinary that she ever suffered as she did in child-bed. She was pregnant twice, and the first child was brought away at the eight months entire, but flattened. In her second labour I saw her. She had gone the full time. When I examined the head of the child, I found it perforated, and one of the parietal bones brought away. After this, the other parietal bone was brought away by the use of the crochet. The hook was then put into the foramen magnum and the base of the skull brought down obliquely, but the operator with all his force could not bring it through. This was on the second day of her labour. She was much exhausted. Her voice, however, was hale and strong, and • she would talk in her usual style of impudence. She sank rather rapidly, and died undelivered. A model represents the appearance which presented on dissection." (See " Obstetrical Collection.") The pelvis is greatly flattened. "It measures, between the sacrum and pubis, two fingers' breadth only, or an inch and a half, the transverse diameter four inches and a quarter. The linea pectinia forms here a very sharp spine, as sharp as a paper-folder. This was the cause of death, for in attempting to bring the head through the pelvis, the womb was forced against the ridge, and being pressed continually, gave way, so that part of the child escaped through the rent in the womb. As in the following specimen, the arm-bone is shaped by the action of the deltoid muscle. The muscles of the shoulder were very powerful, and she took great pride in the rapidity of hei' progress." 2 1 2 Diseases of Bone. The skull is well shaped, with the hones somewhafc irregularly thickened, although to a less degree than in the pre- vious specimen. The spine and thorax, as well as the scapulse and clavicles, show no marked change. The humeri are very irregular and short, with great development of the ridges, especially that of the deltoid, and marked prominence of the inner condyles. The bones of the fore-arm are small and some- what bent forward, especially on the right side, with an exaggeration of most of the bony ridges, and an enlargement of the lower ends of the radii. The pelvis, as already noted, is markedly flattened and rickety. The lower limbs are crossed. The femora are short, and have an outward bend at the upper end. The great trochanters are above the level of the head. The lower ends are enlarged, and the linea aspera are unusually prominent. The tibiae and fibulaB are in their crossed position, bent upon themselves, with the convexity directed forwards and outwards relatively to the trunk, but really forwards and inwards in the usual anatomical sense of the word. When the legs are much crossed the soles of the feet look downwards, the insides being, of course, to the outside. The tibiae and fibulae are, as usual, laterally flattened at the bend, considerable bone being thrown out in the concavity of the curve. The bones of the feet are soft and lidit. B. C. i. 3. M. 23. 6. 27. Skeleton affected by Rickets. — Skeleton of an adult woman, showing changes chiefly in the spine, pelvis, and lower limbs. Thorax and spine show changes characteristic of lateral curvature, with convexity to the right in the mid-dorsal region. The bodies of the verteDrte are, as usual, rotated towards the convexity, and the right side of the chest is raised, carrying the scapula with it. In the concavity of the curve the bodies of the vertebr£e are greatly compressed and fused together, the corresponding libs being also compressed and anchylosed |to the verteltrae, a'.;d their angles flattened. On the convex side Rickets. 213 the angles of the ribs are as usual unduly prominent. The lumbar spine is comparatively unaltered. The pelvis is flattened from before backwards, and the lower end of the sacrum and coccyx project into the outlet. Lower Limbs. — The bones of the right leg are longer and better developed than those of the left. The femora on both sides are curved forward near the upper end. The tibiae and fibula? are bent forwards and inwards, this change being specially seen on the left side, where the shape of the fibula reminds one of an Australian boomerang, and has been firmly pressed against the tibia. There is a very marked projection on the outer side of the os calcis on either side. The bones of the upper limbs are not so much distorted as those of the lower. They show a certain degree, especially in the humeri, of the alteration noted in the previous skeleton, but the changes are much less than in the lower limbs. The right radius seems to have sustained a Colles' fracture. B. C. I. 3. M. 28. 6^ 28. Skeleton affected by Rickets. — Skeleton of an adult woman — macerated, showing rickety changes in the lower limbs and pelvis. There is a very slight lateral dorsal curve, not sufficient to have distinctly altered the thorax. The pelvis is somewhat flattened from before backwards. In the lower limbs the femora are curved forwards and outwards at the upper ends, and the linea aspera in each case is remarkably prominent. The tibice and fibulae are bent inwards about the middle, with the usual ridges on the concavity. The bones of the feet show scarcely any alteration, except for the prominence of the tubercle on the outer side of the os calcis. B. C. i. 3. M. 22. 6. 29. Distortion of the Sternum from Rickets— Sternum and costal cartilages from an adult — macerated, to show the above. 214 Diseases of Bone. The bone is much increased in breadth (3 inches in manu- brium) but is stunted in length, and the angle of Luoerature continued high, the leg was amputated above the knee, one week after his admission. The knee-joint was found to be suppurating. The specimen shows almost complete separation of the periosteum, except at the lower and slightly at the upper ends of the tibia. It also illustrates the very free incision required for such cases. The injection failed owing to the numerous points at which escape occurred. G. C. 2788, Presented by Professor T. Annandale, F.R.C.S.E. 6. 79. Acute Suppurative Osteo-myelitis of the Tibia- Amputation. — Section of the injected right tibia of a girl — in spirit, shoAving the above. Al)out Christmas 1889, Agnes R. , aged 12 years, blistered a part of her heel, which soon became inflamed and irritable. This was poulticed and then improved. About the 8th of January 1890, her ankle " gave way ' while she was skating, and became afterwards swollen and painful. The swelling, which was at'first near the ankle, afterwards extended to the knee. Shortly afterwards an abscess was opened over the inner malleolus, and speedily others formed, and were opened higher up the leg. Eventually the ankle-joint communicated with one of the abscesses, and the tissues of the leg generally became inflamed. She was admitted to Ward 17, Royal Infirmary, on January 30th, 1890, and shortly afterwards the leg was amputated, just above the knee. A few days later an abscess formed on each shoulder, and that on the left was followed by considerable necrosis of the upper end of the humerus. Similar abscesses formed over each olecranon process. She was greatly emaciated, and after remaining in Hospital for many weeks, was sent to the Incurable Hospital, where she died some weeks afterwards. The specimen shows purulent infiltration through nearly the whole of the medullary cavity of the tibia. It also shows new periosteal bone forming on the surface of the shaft, and complete detachment of the lower epiphysis. G. C. 3260. Presented hy A. G. Miller, F.R.C.S.E., 1891. 6. 80. Acute Suppurative Osteo-myelitis of the Tibia- 234 Diseases of Bone. Amputation. — The outer half of the previous speeimeK> with the fibula — macerated, showing the above. New bone is seen to have been developing on the surface of the shaft of both bones, but especially of the tibia. From the history of the case, it is evident that this new bone must have developed in about three weeks. There is no pei'ceptible change in the bony texture of the medullary cavity. G. C. 3261. Presented hy k. G. Miller, F.R.C.S.E. 6. 81. Acute Suppurative Osteo-myelitis of the Tibia — Amputation. — Water-colour drawing, by John T. Kelly, of Nos. 6.80 when fresh, to show the distribution of the pus in the medullary cavity. G. C. 3585. //. Where the chief changes are in the form of rarefaction and absorption,. i.e. a septic form of " Caries." 6. 82. Acute Suppurative Osteo-myelitis of the Neck of the Femur. — Section of the upper end of the right femur of a child, showing the effects of a recent case of the above. The patient was a girl aged about eleven years, who haid beerk brought up in the workhouse, and was delicate and ill-nourished. She developed symptoms of very acute synovitis of the hip, with great pain, following a slight injury. In a few days tlie pain subsided, and a large abscess formed round the hip, and projected at the back. It was opened and drained, but the child died suddenly next day, apparently from a clot in the heart. No post-mortem examination could be obtained. The specimen shows that the bone has been opened out and softened on the front of the neck within the capsule. This accounts for the synovitis, which must have been suppura- tive. Had the child lived, necrosis of the part below the upper epiphysis might have followed. G. C. 33119'. Presented blJCllkl\\.V.Si^^f. Cathcakt, F.R.C.S.E., 1891. Caries from Pus-forming Organisms. 235 6. 83. Acute Suppurative Intlammation in the Lower Epiphysis of the Femur (Acute Epiphysitis).— Outer half of the right knee of a boy aged four — injected, and in spirit, showing the effects of the above. J. G. was admitted to Ward 18 on the 12th February 1890. He had a satisfactory family history and good previous health. About the beginning of January he had been suddenly seized with a severe pain in the right knee when asleep, and the leg became firmly flexed. This subsided, but was followed by frequent muscular spasms, producing complete flexion and great pain. These increased in severity, and became worse at night. A swelling then appeared in the region of the knee, and these attacks ceased. On admission, he was very weak and thin. The limb was flexed, but could be straightened, and there was considerable swelling in the region of the knee, with pain and tenderness limited to the lower parts of the femur. The knee was treated by extension, afterwards by Scott's dressing and a plaster case. On removing these there were pains on the inner side over the epiphysis, and thickening of the synovial membrane. On the 11th March the painful spot was incised and pus escaped. No bare bone. \Atli March. — The temperature, pain, and swelling were worse, and the wound was " septic. " 20;!/i MarcJi. — Explored and a necrosis of the femur diagnosed. Part of the epiphyseal cartilage was diseased. The joint was opened into and drained. ^^jn7 1. — The patient has been going down-hill, suffering from septicemia, so Mr Cathcart amputated through the thigh. The patient recovered. The softening and destruction of the epiphysis and adjacent portion of the shaft is distinct. An abscess had started to burrow up into the popliteal space. G. C. 3179. Presented by Charles W. Cathcart, F.R.C.S.E. 6. 84. Acute Suppurative Inflammation of the Lower End of the Femur, with Erosion and Rarefaction.— Lower end of the shaft of a right femur (epiphysis wanting) - — macerated, showing the above. "The patient, G. Y., aged 16, stated that, seven weeks ago, while walking, he was tripped, and his knee came in contact with a small stone. This caused no visible injury. He continued walking for two days after, when his knee swelled and became extremely painful. These symptoms, accompanied with much febrile irritation, continued for a month, during which time leeches and cold applications were first em- ployed, and afterwards poultices and fomentations. Three weeks ago an 236 Diseases of Bone. abscess was discharged at that point where the cicatrix now remains, and about a pint of pus escaped. From this opening matter continued to flow in large quantities, till Monday last, when it had healed. His state of health had been gradually getting worse. " The knee, especiall}' on its anterior part, is much swollen, and its surface somewhat red and exquisitely painful. The patella is anchylosed. In the cavity of the joint there is a collection of fluid, aff"ording a very distinct sense of fluctuation. The knee is preserved in a semi-bent position, and its motions are altogether lost. At its upper and inner part there is a small cicatrix. The inferior part of the thigh is also swollen, and the foot freqiiently cedematous. Several glands in the right groin are enlarged and painful on pressure. His general health is much impaired. There is much emaciation and debility — pulse 125, small — appetite bad — frequent night sweats — tongue clean — bowels slow. " On examination, Dr Hunter found that the femur was enlarged and diseased about three inches below the trochanter major. On 25th inst. he slept some — pulse 132, small — some sweating during night — tongue clean — some thirst. The cicatrix was opened up to-daj^ and about ten ounces of sero-purulent matter was discharged from the course {sic) of the femur. ' ' After admission the patient showed symptoms of septic poisoning. There was a very extensive discharge, and as he was getting weaker, it was thought better to amputate below the small trochanter, from which he made a good recovery." The lower half of the specimen is very irregular, showing small patches of necrosed bone, with depressions and erosions round about them and numerous holes. There is also some deposit of new periosteal bone in the neighbourhood. This seems to have been a case of advancing septic inflam- mation in the bone. G. C. 1004. Presented by kv)A.^i Hunter, F.R.C.S.E. 6. 85. Acute Suppurative Inflammation of the Upper End of the Femur, with Rarefaction and Loss of Substance. — Upper half of a right femur, probably that of a woman — macerated, showing the above. The interior of the head has, in many places, disappeared) and the back and under surfaces of the neck are irregularly and extensively opened out and absorbed, some of the bone on the interior seeming to be necrotic. The bone below the small Caries from Pus-formi'ng Organisms. 237 trochanter has been reduced to a thin shell, existing only on the outer side. This has been fractured, possibly in the process of preparation. Below the seat of fracture some new periosteal bone has been thrown out on the surface. This has evidently been a case of advancing septic inflammation. B. C. 2. M. 4. 6. 86. Acute Suppurative Inflammation of the Cranium.— Lower half of a cranium, lower jaw and first three cervical vertebrae — macerated, showing the above. The patient, an old lady aged 75 years, had suffered from a most severe attack of erysipelas of the face and head, accompanied by very great oedema and swelling of the soft parts, and followed by their destruc- tion. Caries soon occurred on the mastoid process, and rapidly spread to the neighbouring bone. Ere long the carotid artery was laid bare, and was seen pulsating against a sharp portion of the petrous portion of the temporal bone. It ruptured in a day or two, and fearful htemorrhage occurred. Dr Foulis at once stuffed up the large hole which had been formed in the side of the head by the destruction of the soft parts and bone with a lump of cotton wadding. This stopped the bleeding, and the lady lived for four days afterwards. The squamous and mastoid portions of the temporal bone, with the great wing and outer ptergyoid plate of the sphenoid as well as the condyle of the lower jaw, have disappeared. The surfaces of bone which lay next to the missing parts are rarefied and absorbed. The vertebras have evidently been injured in being removed, but parts of their surface have also been attacked by the disease. G- C. 2647. Frese7ited hj J AWES Fotjlis, M.D. 6. 87. Acute Suppurative Inflammation of the Sternum leading" to Destruction. — Lower end of a sternum and costal cartilages, showing the above. The specimen was obtained from a patient who died in the Royal Infirmary, Edinburgh, in 1824, after a head injury, for which trephining had been performed. The cause of death was therefore probably jiya^mia, in the course of which an abscess had formed in the sternum. 238 Diseases of Bone. The lower part of the bone, especially on the left side, has disappeared, and the surface round the missing part has been opened out and eroded. G. C. 596. c. Where the chief changes ara in the form of enlargement. 6. 88. Thickening- of the Femur from Chronic Suppur- ative Inflammation of the Compact Tissue. — Left femur — macerated, to show the above, A portion of the new shell has been removed, to expose the condition of the original surface. The periosteal crust is about a quarter of an inch thick, while the original compact tissue is opened out and partly absorbed. This, therefore, seems to have been the seat of the disease, which, by its irritation, has led to the development of new bone from the periosteum. B. C. i. 5. M. 23. 6. 89. Thickening* of the Femur from Suppurative In- flammation of the Compact Tissue.— Anterior half of the upper end of a left femur — macerated, showing the above. The specimen is from the body of a man about 34 years of age. He had complained for nearly eight months of acute pain in that thigh, which gradually swelled, anil eventually was opened, and disciiarged a large quantity of pus. The medullary cavity is partially filled up by newly-formed cancellous tissue. Opposite this place, on the outer side, the compact tissue has been opened out. On the surface much new bone has been formed, so as to produce a considerable thicken- ing, v.diich gradually fades oflf into a thin periosteal crust upon the other parts of the shaft. The section has passed through a depression on this enlargement. In this case, therefore, the suppurative inflammation has found an exit opposite the centre of the new mass, and has not caused either necrosis or bone abscess. G. C. 1636. Presented by J. Newbiggino, F.R.C.S.E. Enlargement frtwi Pus-forming Orgcmisms. 239 6. 90. Thickening- of the Femur from Chronic Suppura- tive Ostitis. — Right femur — macerated, showing the above. The bone is much curved forwards near its lower end, and is correspondingly flattened from side to side. The posterior aspect of the bone is very rough and irregular, but the surface elsewhere is smooth, except where there are impressions left by blood-vessels. This seems to have been a case where chronic ostitis had led to softening and yielding of the bone, with sub- sequent solidification. W. C. G. 34. 6. 91. Great Thickening- and Irreg-ularity of the Surface of the Femur, from Chronic Suppurative Osteo- myelitis.— Right femur, in section, showing the above. There is great thickening of the bone and extraordinary irregiilarity of its surface. Along the back, and on all aspects of the upper third, the surface is thrown out into large irregular pro- cesses and plates, a condition which is also seen, to a less extent, along the front, The medullary cavity is completely filled up by cancellated tissue, except for about an inch near the upper end. At the junction of the upper and middle thirds the new bone shows several irregular cavities communicating posterially with the surface. These have probably been due to localised suppuration or minute necroses. One or two similar cavities are seen scattered throughout the bones. G. C. 1000. 6. 92. Great Thickening- of the Femur from Chronic Suppurative Osteo-myelitis. — Right femur in section — macerated, showing the above. There is very great enlargement of the shaft of the bone, with some dilatation of the medullary cavitj^ near the lower end. The surface of the bone along the back and at the muscular attachments of the trochanters is irregular, and the vascular channels are greatly enlarged all over. The wall of the shaft is almost entirely composed of cancellated tissiie. B. C. I. 5. M. 26. 240 Diseases of Bone. 6. 93. Thickening- of the Surface of the Tibia with Absorption of the Interior, probably from Chronic Suppurative OsteO-myelitiS. — Lower end of a right tibia — macerated, shoAving the above. There has been a considerable crust of new periosteal bone on the surface, which has been, however, partly broken oflf. The original surface of the bone is porous, and at places has been opened into small holes. G. C. 1 1 47. Presented by Professor James Russell. d. Where the changes in the bone tissue have resulted in an abscess. 6. 94. Abscess in the Lower End of the Radius. — Lower end of a left radius — macerated, showing the above. Above the articular surface there is considerable enlarge- ment and hollowing out of the interior, probably due to chronic suppuration. Three cloacal apertures communicate with the inside, and through them pieces of rarefied and apparently necrotic bone can be seen. The surface has the irregular character of newly-formed bone wdien due to the irritation of suppurative organisms, B. C. i. 5. M. 14. 6. 95. Abscess in the Lower End of the Femur.— Left femur — macerated, to show the above. The lower half of the bone is greatly enlarged by new and irregular formation on the surface.. The interior is hollowed out, and formerly contained fragments of necrosed bone. This has evidently been a case of suppuration within the lower end of the bone, causing osseous development on the outside. W, C. G. 29. 6. 96. Abcess in the Lower End of the Tibia.— Section of a left tibia with fibula, showing the above. Bone Abscess. 241 The lower end of the tibia is much enlarged, and there is a cavity in the interior extending half-way up the bone, but partially interrupted by cancellous tissue. The enlarged part of the bone has been trephined, and the upper end of the cavity has been reached, but drainage has evidently been incomplete, for the lower portion of the cavity communicates by only a narrow aperture with the trephine hole, and is enlarged. The periosteal thickening of the tibia corresponds to the cavity inside. The fibula is enlarged about its middle, and especially on the inner aspect. G. C. 3212. Fresented by k. G. Miller, F.K.C.S.E. 6. 97. Abscess in the Lower End of the Tibia.— Left tibia, in section, and fibula — macerated, showing the above. The surface of the tibia on the lower two-thirds shows considerable alteration. A large node-like swelling is seen in front, about the middle. Below this there is a considerable deficiency, with an aperture leading from it into a cavity situated above the lower articular surface. The walls of the cavity are lined by cancellated tissue, with only slight thicken- ing round the sides. The bone tissue however, above and below the cavity, is condensed. The upper end of the bone seems normal. The fibula is thickened near the affected part of the tibia. The appearances are not typical of an ordinary bone abscess, and the condition may have been tubercular. F. P. C. 423. 6. 98. Abscesses and Chronic Ostitis in the Tibia.— Lower two-thirds of a fibula, and section of tibia — macerated, to show the above. " Twenty-six years ago the patient, T. S., a man aged 39, was affected apparently with necrosis of the tibia, which bone is evidently much enlarged. Nine years ago he was first attacked with his present complaints, from which he recovered completely in five months, and continued perfectly well until within six months of the present date, when he again relapsed, after exposure to cold and wet. Q 242 Diseases of Bone. "A little in front of the right malleolus externus there is the orifice ■of a sinus which runs underneath the extensor tendons, and terminates by .another opening a little below the inner malleolus. From both of these orifices the probe may be passed into the articulation of the astragalus and tibia, the articulating surfaces of which bones are felt rough ; discharge copious but healthy ; the motions of the joint are very confined, and the surrounding parts much swelled and slightly inflamed. General health pretty good ; pulse 100 ; tongue a little furred ; slight sweating ; bowels rather costive.' The leg was amputated by the single flap operation two or three •days after his admission, and he made a good recovery. When fresh, "the tibia was dry, of a deadly whiteness, and not a particle of blood or of marrow oozing from its cut surface." "The tibia appears to have been the seat of long-standing and inveterate disease. This bone is enlarged throughout its whole length, but more particularly at its extremities, and on laying it open by a longitudinal section you observe its whole medullary cavity occupied by osseous depositions. This internal structure has been in several places the seat of caries, or, perhaps, I should rather say, of internal abscesses. A small one is observable just at the point where the bone was cut across in removing the limb, another immediately below this point, a third towards the middle of the bone, and a fourth very large •cavity is situated in the distal extremity of the tibia immediately above its junction with the astragalus. This cavity, in the recent state, contained a quantity of purulent matter. It opens in front by a circular aperture immediately over the ankle joint, and it was, I suspect, into this opening that the probe passed when I conceived it to be going into the cavity of the joint. On the posterior surface of the bone, nearly opposite to the seat of this abscess, you will find some adventitious deposition of ossific matter in a stalactitic form. The fibula scarcely presents anything worthy of notice. Its lower extremity is divested of its articular cartilage, and apparently roughened, but whether this is the effect of disease or maceration is not very easily determined." (Sir George Ballingall's Clinical Lectures, No. 4, p. 18.) The pockets on the wall of the lowest abscess cavity in the tibia resemble somewhat the results of tubercular invasion, but Bone Abscess. 243 the history of the case seems to point sufficiently clearly to the agency of pus-forming organisms. G. C. 1119. Presented by Sir George Ballingall. 6. 99. Disease of the Astrag^alus and Fatty Degeneration of the other Tarsal Bones, secondary to the above Condition of the Tibia. — Bones of the right foot from the same patient as the last specimen — macerated, to show the above. " The whole bones of the foot, although not showing much disease, were so extremely soft and pulpy as scarcely to admit of articulation. They could have been cut across in all directions with a common scalpel without turning its edge." The articular surface of the astragalus seems to have been affected more from the anchylosis than from the actual dis- ease. Some of the roughness on it may have been caused in process of preparation. G. C. 1119. Presented Inj Sir George Ballingall. 6. 100. Abscess and Chronic Ostitis in the Lower End of the Tibia. — Lower part of a right tibia in section — macerated, illustrating the above. The bone is greatly thickened, owing to new formation of cancellated tissue. The large cavity at the upper part is continuous Avith the medullary canal. A small cavity seen below on the front section has its walls formed of condensed bone. This condition has apparently been the result of chronic septic osteo-myelitis in the lower end of the bone, ending in suppuration in one or two places. W. C. G. 14. 6. 101. Enormous Enlarg-ement of the Upper End of the Tibia, from Abscesses in the Interior.— Section of a 244 Diseases of Bone. right tibia, with fibula attached— macerated, showing the above. " Charles Anderson, xt. 31. In summer 1814, while on a voyage to the Baltic, he fell on deck with his leg under him. This fall was followed by great swelling below the knee and inability to use the limb. On getting into Riga, ten days after, he was carried to a surgeon, who considered the injury as slight, and gave him a liniment to rub with. He continued this for about a week, and got a little better, so as to be able to walk on crutches — though not to put his foot to the ground — when he had a second fall in crossing the street. He was now carried to a Hospital in Riga, where he was told that the bones below the knee were splintered into several pieces, and was confined to bed for six weeks. He then left the Hospital and came home, still quite unable to walk, and the swelling as great as ever. In winter 1815-16 he was in the Edinburgh Infirmary for about a fortnight, when amputation was pro- posed, but to this he would not consent. In spring 1817, the swelling, which at this time appears to have been only partially ossified, was cut into by a surgeon in Dundee, and discharged a little bloody pus, but soon healed up. In winter 1817-18 he had a severe fever, during which an opening formed where the incision had been made. After liis recovery from the fever, he felt the limb much stronger than it had ever been since the accident, and was soon able to walk. Since then the sore has continued open, discharging commonly a bloody serum, sometimes mixed with blood and purulent matter, and at different times portions of splintered bone, which, he says, could be seen, for months before being discharged, imbedded in the osseous walls of the cavity. The discharge at first was not great, but has gradually increased to eight, twelve, and sometimes even sixteen ounces in twenty-four hours. When he began to walk, he was obliged to use a plug of wood and tow, at first small, but gradually enlarged as the aperture increased to its present size. This he removed once or twice a day, and discharged the fluid from the cavity, which was then washed out, and filled with tow or sponge. His health for the last twelve years had been good, till within six or eight months of this time, when hectic symptoms began to appear, with increased discharge and pain after unusual exertion or exposure to cold. Since 1820 he has been employed as clerk to a manufacturer, when he often had occasion to exert himself considerably in weighing flax, and was able to use the diseased limb nearly as well as the other, and has sometimes walked upwards of twenty-four miles in one day." Note by Dr E. Knox. — "On examining the limb . . . the following appearances were noted : an extensive swelling or tumonr occupying the superior third of the leg, and extend- ing from close to the knee-joint downwards. This tumour seemed to be composed of an osseous sheet, formed apparently at the expense of the tibia, as the fibula could be traced from Bone Abscess. 245 below iipwcards, apparently unconnected -with it. The integu- ments were everywhere sound. On the anterior and somewhat inner aspect of the limb a circular opening, rather more than an inch in diameter, led into the interior of the bony case. The integuments passed into the opening for a short way, passing insensibly into a soft mucous-looking membrane lining the whole interior of the osseous case, and seemingly occupying the centre of the tibia. These facts were observed before any dissection, on merely removing the plug mentioned in the case above, which the patient used to insert and withdraw at pleasure, so as to allow of the escape of matter and the washing •out of the cavity. On dissecting the limb, these conjectures, as far as they regarded the nature of the tumour, were found to be correct. A section of the tibia in its long axis showed the upper part of the tibia dilated into an enormous cavity, -capacious enough to contain sixteen and a half ounces of fluid, lined throughout by the membrane already spoken of, and communicating externally by means of the aperture, which the patient was in the habit of plugging up. The lower portion of the tibia was quite sound, and scarcely, if at all, altered from its natural appearance. The medullary cavity of this sound portion did not communicate with the diseased cavity above, -nor do the walls of the cavity itself present any very remarkable or diseased appearance, and they are of considerable thickness. Of the surrounding soft parts — muscles, nerves, arteries, etc. — it juay be said that they were perfectly healthy. The muscles which ran over the tumour were put greatly on the stretch, but in all respects quite healthy. Indeed, the change affecting the tibia was limited entirely to itself, nor did the periosteum covering it show any diseased appearance or change of structure." The following points may be noted on this macerated portion. The inner wall of the cavity presents a surface formed of opened-out, carious-looking bone, showing at some places necrotic and almost loose portions, and at others irregu- lar pockets, probably resulting from the separation of necrosed fragments. The wall of the cavity, which varies from one- 246 Diseases of Bone. quarter inch to one inch and a quarter in thickness, is chiefly formed of porous bone, but it is more condensed externally, and is densely compact where it joins the shaft. At the upper end the wall itself has been the seat of one or two small abscesses. The outer surface of the expanded portion and of the shaft below is thrown into the irregular plates characteristic of chronic periosteal irritation. The fibula has a few bony spicules upon its inner surface, but it is chiefly remarkable in having been gradually flattened out, and bent so as to fit on to the adjacent surface of the expanded tibia. The cavity has evidently been formed by new growth on the outer surface, with absorption from within. G. C. 1219. Presented hy Professor James Russell. 6. 102. Enormous Enlarg-ement of the Upper End of the Tibia from an Abscess in the Interior. — The other half of the foregoing specimen — in spirit, illustrating the above. This specimen shows the abscess cavity lined with granula- tions, also the plug of wood and tow alluded to in the history of the case, as when the patient wore it. G. C. 1218. Presented by Professor James Russell. 6. 102a. Oil painting of the preceding preparations in their recent state. F. P. C. 15. a. e. Where the chief changes are in the form of necrosis or death of a palpable portion. (a.) Where the dead piece has been in j^rocess of separation. 6. 103. Acute Suppurative Osteo-myelitis and Periostitis of the Tibia^NecrOSiS. — Portion of the tibia of a boy, with adjacent soft parts — injected and in spirit, to illustrate the above. The patient, a boy aged 12 years, had suffered from an inflammation considered to be erysipelatous, following exposure to cold. "In conse- Necrosis from Pus-forming Organisms. 247 quence of sinking from hectic fever, amputation was performed, but he died two weeks after." The specimen shows an area of bare dead bone, with a great thickening and vascularity of the periosteum on what had been living. The dead bone has been pitted on the surface by the vascular granulations, which have been lifted up in many places to show this. Other vascular granulations can be seen here and there coming through the bone from below. At one place there is a narrow grey strip of new periosteal bone. This has evidently not been a case of erysipelas, but of the above, a disease often mistaken for it. These cases often die, as this one probably did, of septic poisoning, with or without pyaemic complications. G. C. 2228, Prcscnteo? % Alexander Watson, F.R.C.S.E., February 1837. 6. 104. Acute Suppurative Osteo-myelitis and Periostitis of the Tibia — Necrosis. — Tibia of a young person, with adjacent soft parts — mounted in spirit, to illustrate the above. The entire shaft has apparently been involved. This specimen resembles the last in the death of portions of the shaft, thickening of the periosteum at other places, and in pit- ting and erosion of the dead parts by the granulations of the living. G. O. 3o52. 6.105. Acute Suppurative Osteo-myelitis and Periostitis of the Tibia— Necrosis.— Section of the upper half of a tibia — injected and mounted in spirit, to illustrate the process of separation of necrosed fragments. The disease was started by a blow upon the tibia. "Mr Benjamin Brodie took notes of this case, when the patient was in Hospital (IMiddle- sex) 1806." There is a large piece of necrosed bone in front, and other smaller pieces below and behind. The dead parts are indicated by bristles and are whiter than the rest. The process of 24:8 Diseases of Bone. separation may be specially studied on the large fragment in front. There the vascular granulations which have separated it from the living stand out as a deep red line all round and below it. A similar process may be observed, only less distinctly, in connection with the other smaller fragments marked by bristles. The periosteum has formed a crust of new bone around the original shaft, except opposite the large necrosed fragment, where it has probably been itself destroyed. W. C. G. 25. 6. 106. Acute Suppurative Osteo-myelitis and Periostitis of the Tibia — Necrosis. — Section of the lower half of the same tibia as the last — injected and mounted in spirit to illus- trate the above. Some of the original cancellated tissue is seen in the interior. Outside this, and marked by bristles, there are necrosed portions of the original compact tissue, and beyond that again there is a thick layer of newly formed periosteal bone. This is irregular on the surface, and shows at one place a cloacal aperture for the escape of pus from the neighbourhood of the dead bone. W. C. G. 24. 6. 107. Acute Suppurative Osteo-myelitis and Periostitis of the Tibia — Necrosis. — Wax cast of a leg, illustrating the above. This cast was figured in Russell on "^N'ecrosis," published in 1794, plate v, fig. 1. The wax was apparently not changed at all as yet (1893). G. C. 1177. Presented by Professor James Russell. 6. 108. Acute Suppurative Osteo-myelitis of the Tibia and Femur — Necrosis. — Plaster cast of the inside of the thigh and leg of a young person, showing the above. Necrosis from Pus-forming Organisms. 249 There has been considerable swelling in the region of both femur and tibia, with several granulating points, which have been the outlet of sinuses communicating through cloacae with the dead bone. F. P. C. 2878. 6* 109. Acute Suppurative Osteo-myelitis of the Tibia- Necrosis. — Plaster cast of the left leg and foot of a young person, illustrating the above. There has been a necrosed fragment lying exposed on a large ulcer in front of the tibia and surrounded by granulations as in the previous case. The limb has been swollen. F. P. C. 2876. 6, 1 10. Acute Suppurative Osteo-myelitis of the Tibia- Necrosis. — Plaster cast of part of the left leg and foot of a child, illustrating the above. The knee has been acutely flexed and the foot extended. Both leg and foot have been swollen, and the dead bone has been not only exposed and surrounded by granulations as in the previous case, but its upper end has been partly extruded. F. P. C. 2879. 6* 111. Acute Suppurative Osteo-myelitis of the Tibia- Necrosis.— Plaster cast of the front of a leg, in which, as in the previous case, a portion of dead bone has been partly extruded from the tibia and surrounded by granulations. F. P. C. 2881. '6« 112. Acute Suppurative Osteo-myelitis of the Radius- Necrosis. — Lower end of a right humerus, with the radius 250 Diseases of Bone. and ulna — muscles partly cleaned off and in spirit to show the above. W. B., a weaver, aged 21, was admitted to the Royal Infirmary, Edinburgh, on 21st May 1824. Fifteen weeks previously the disease began with erysipelas of the part, followed by formation of abscesses in different parts, and of sinuses similar to that now at bend of arm. Some of these have never healed, and he has had two subsequent attacks of erysipelas. Was in the House from March 23rd to April 16th. Dismissed by desire." On his second admission, "the whole of the right fore-arm is swelled and particularly tender, especially at the elbow and wrist, where the enlargement is equable and very hard, and where there are sinous openings leading down to the bone. The granulations at the mouths of these are prominent, and there is a fungus forming over the carpus a large irregular unhealthy ulcer. The joints appear anchylosed ; motions of the hand, which is distorted inwards, lost. The attempt to move the hand in any direction attended with great pain. Great general weakness and copious sweating. Pulse 102, firm ; tongue clean ; bowels costive ^ appetite pretty good." The arm was amputated by Mr Allan at about two inches above the elbow. The patient did well for three days after the operation, but on the evening of the third day he had severe rigors, followed by profuse sweating and other symptoms of pyaemia, which continued till his death. The stump suppurated extensively. The pus ran up to the shoulder and affected the joint. Patient sank exhausted on the 16tli July. (See No. 6.181.) The radius is enlarged over its whole extent by develop- ment of new bone on the surface. At the back, near the lower end; there is a large fragment of dead bone, which is free above, but surrounded by a new shell below. The ulna does not appear to have been involved by the disease. G. C- 981. 6. 113. Acute Suppurative Osteo-myelitis of the Femur — Necrosis and Rarefaction. — Left femur — macerated, show- ing the above. " The man received a blow from a mallet on the thigh. A deep and large abscess formed. He died. An abscess surrounded the thigh-bone^ which broke when being raised." On the posterior portion of the lower end of the shaft there- is a large necrosis, smooth and white, and partially separated from the surrounding bone. The groove of separation is much deeper above than below, where at places it is very indefmite.. Necrosis from Pus-forming Organisms. 251 Another smooth necrosed patch is seen in front of the small trochanter, and is evidently portion of a large and deep necrosis. Before the fracture this has apparently been continuous with the loAver necrosed piece. Some new bone has been thrown out on the front of the shaft, and also behind for a few inches below the seat of fracture. The cancellated tissue at the upper and lower ends of the bone, especially near the necrosed portion, has been rarefied, and is a good illustration of what has been already noted as septic caries. (See Nos. 6.82 to 6.87.) B. C. I. 1. M. 24. 6. 114. Acute Suppurative Osteo-myelitis of the Femur. ^Left femur of a young person — soft parts cleaned off and in spirit, to show the above. There is a fracture about the middle of the bone, which may have been a compound one, and therefore possibly the starting-point of the disease. A large portion of the whole thickness of the shaft below the fracture is smooth, and evidently has necrosed. It has been in process of separation from the bone below. Above the fracture, for some distance, there has been some periosteal new growth. Just below the level of the small trochanter the bone has been entirely destroyed. Loose fragments of necrosed bone are seen here and there at the upper end of the shaft. The substance of the bone above this point has been softened and partially absorbed, and has been separated into distinct pieces, some evidently necrotic. The whole bone, with the exception of the lower epiphysis, seems to have been affected. This specimen, like the last, illustrates what might be called septic caries and septic necrosis. If it were certain that the disease in this case had resulted from a compound fracture, this specimen would have been placed in group B, i.e. among those in which pus-forming organisms have attacked the bones through wounds. G. C. 3353. 252 Diseases of Bone. (b. ) Where the dead piece has become loose, but has remained in position, and has acted as a source of irritation. 6. 115. Acute Suppurative Osteo-myelitis of the Femur- Necrosis, Fracture. — Lower half of the right femur of a lad, aged 18 — macerated, to show the above. Three years before amputation a large abscess formed in the patient's right thigh. This was opened, but had continued to discharge for six months, when he fell and fractured the affected femur. Union took place, but at an obtuse angle, and the previous discharge of matter continued. A probe when passed into the opening came in contact with bone, but no loose portion could be discovered previous to the amputation. This difficulty was afterwards explained when it was found that the sequestrum had been covered posteriorly by a mass of semi-cartilaginous substance fully an inch in depth, which occupied the popliteal space, and was distinctly continuous with the thickened periosteum. At the back of the preparation there is a large sequestrum, loose, but partially surrounded by the neighbouring new shell. The lower end of the shaft, which is for the most part of new formation, is curved forwards just in front of the sequestrum. The latter has evidently been pressing against the bone above and below the bend, and thus must have acted mechanically in preventing the bend from increasing. The surface of the new shell blends with the original bone at the knee and towards the middle of the shaft. G. C. 2111. Presented by Benjamin Bell, F.R.C.S.E., 1840. 6. 116. Acute Suppurative Osteo-myelitis of the Femur- Necrosis, Anchylosis of the Knee, and Atrophy of the Tibia. — Section of the lower end of a femur and upper end of a tibia— macerated, to show the above. The patient, a young person, suffered about two years before amputa- tion from acute suppuration and inflammation of the femur, which ended in necrosis. He had not been treated, and had lain with his knee very much flexed. Amputation was performed through the thigh by Pro- fessor Annandale. The specimen shows a sequestrum in the femur, lying now loose in a cavity, with considerable development of new bone near and partially surrounding it. The new bone towards the Necrosis from Fiis-forming Organisms. 253 knee becomes very delicate, and. at the knee there is practically no bone at all. The bone forming the upper end of the tibia is reduced to a shell with numerous apertures in it. The shaft of the tibia is also reduced to a hollow and fragile shell, which in many places is perforated by apertures. The contrast between the atrophy of the tibia and the new bone development round the sequestrum in the femur is very striking. G. C. 3499. Trcsented hy Alexis Thom.sox, F.R.C.S.E., 1893. 6. 117. Acute Suppurative Osteo-myelitis of the Femur- Necrosis, Anchylosis of the Knee, and Atrophy of the Tibia. — Water-colour drawing by John T. Kelly of the previous specimen, when fresh. The drawing shows the enlargement of the femur, and the sequestrum lying in its cavity surrounded by grey gelatinous material. Near the lower end of the shaft of the femur the new bone is shown opened out in texture and the epiphysis and adjacent part of the shaft entirely occupied by a brown fatty material. The same substance is seen in the section of the patella and tibia. The cancellated tissue in the tibia is entirely absorbed and the bony shell is very thin. The muscles round the bone were very soft and fatty. G. C. 3500. 6. 118. Acute Suppurative Osteomyelitis of the Femur- Necrosis, Amputation. — Sequestrum of the lower portion of a femur, partially surrounded by a shell of new bone — macerated, to show the above. The disease began in the knee-joint. A partial case of new bone has formed round it. The surgeon in charge of this patient wished to amputate at the hip-joint, but on Sir Charles Bell's advice, he amputated through the thigh, with complete success. The sequestrum, which has included the greater part of the lower end of the shaft, has been completely separated 254 Diseases of Bone. from the adjacent bone. The new shell has been too imperfect to have been functionally useful, B. C. i. 5. M. 41. See Sir Charles Bell on " Spine and Thigh Bone," plate v. fig. 2. 6. 119. Acute Suppurative Osteomyelitis of the Femur- Necrosis. — Portion of a femur — macerated, to show the above. A rough piece of necrosed bone is surrounded by a nearly complete case of irregular new bone. At one part the new case is deficient and the sequestrum exposed. At other places cloacae are seen. On the side opposite the deficiency an attempt was made to destroy the new bone by the actual cautery, in order to remove the sequestrum. The black burned part has no doubt been killed, and has been in process of separation from the rest as is indicated by the sulcus round it. B. C. I. 5. M. 33. 6. 120. Acute Suppurative Osteo-myelitis— Necrosis, Chronic Enlargfement. — Section of a part of a femur — macerated, illustrating the above. The new bone in most places is as dense as ivory, while at other parts it is cancellous. Several cloacal apertures communi- cate between the surface and the cavities within. In one of these cavities a loose fragment of dead bone is seen. The others have probably contained similar fragments, which have dropped out. The walls of the cavities are porous, and might be called carious. They have been covered with granulations, from which suppuration has come. The outer surface of the bone presents the usual irregular character seen in such cases due to the active development of new periosteal bone. This specimen shows by the density of the new bone how extremely difficult it is in some cases to remove enclosed sequestra. B. C. i. 5. M. 40. Necrosis from Pus-forming Organisms. 255 6.121. Acute Suppurative Osteo-myelitis of the Tibia- Necrosis, great periosteal Enlarg-ement, Amputa- tion.— Left tibia, showing an enormously thickened case of new bone round necrosed fragments. " James B., aged 20, labourer, admitted to the Royal Infirmary, Edinburgh, November 1825. ' ' Three years before amputation the disease commenced without any cause, and with a very severe pain. Inflammation, swelling, and suppura- tion ensued a year after this. A piece of bone was discharged. The sinuses have gradually increased in number, from which a great quantity of small bones have been discharged. His general health began to suffer about three months before amputation. "On 20th November 1825 the following was observed. Upon the anterior part of his left leg are numerous small ulcerations, all of whichlead down to the tibia, which can be felt to be in a state of caries. The limb, particularly at its lower part, is swollen and altered in form. From the sinuses there is a great discharge of pus, of a very fcetid odour. He experiences a constant dull pain. His general health is very much im- paired, and his strength much reduced. Pulse 100. Frequent shivering and flushing of the countenance. Incessant thirst, tongue red, bowels loose. " The limb was amputated through the thigh, but the patient died of septicemia and secondary hemorrhage." This is a beautiful example of a new periosteal shell formed round necrosed fragments. Numerous cloacal apertures may be observed, especially along the inner surface of the bone, and sequestra can be seen through these apertures, lying loose, but imprisoned within the new shell. G. C. 1000. a. 6. 122. Acute Suppurative Osteo-myelitis of the Tibia- Necrosis, Chronic Periosteal Enlargement. — Lower end of a right tibia — macerated, to illustrate the above. This specimen closely resembles the lower end of the previous one. INo doubt there has been a similar clinical history. G. C. 1160. Presented by Professor James Russell. 6. 123. Acute Suppurative Osteo-myelitis of the Tibia— 256 Diseases of Bone. Necrosis, Periosteal Enlargement.— Tibia of a young person, in which the shaft having been necrosed has been surrounded by a new shell — macerated. In this case there is a central sequesttum, which has originally consisted of almost the entire shaft. During the process of separation, however, it has been partially absorbed, and, as seen through the cloacae, it is in many places rough and irregular. The shell surrounding the sequestrum, although so well formed, is slightly bent. It has numerous cloacal apertures. G. C. 1183. Figured in Russell on " Necrosis," plate i. page 177. 6. 124. Acute Suppurative Osteo-myelitis— Necrosis, Chronic Periosteal Enlargement. — Portion of the shaft of a femur or tibia — macerated, illustrating the above. A section has been made of part of the new case to show its thickness. The sequestrum has evidently included the greater part of the diaphysis. The surface of the new case at places is eroded, but this has probably happened during the preparation of the specimen. B. C. i. 5. M. 37. 6. 125. Acute Suppurative Osteo-myelitis of the Tibia- Necrosis, Chronic Enlargement. — Lower two-thirds of the right tibia of a young person^injected, soft parts cleaned off and in spirit, illustrating the above. Upon the front of the preparation there is a considerable excavation, and in a crevice at its lower end there is a small loose scale of necrosed bone. The appearance of excavation is evidently due to irregular development of new bone round a superficial necrosis, which has now disappeared. This was formerly described as an ulcer of the tibia. If an ulcer of the skin had been present over the affected part of the tibia, as is probable, the ulcer in this case will have been secondary to the bone disease. B. C. i. 5. M. 2. Necrosis frotn Pus-forming Organisms. 257 6. 126. Acute Suppurative Osteo-myelitis of the Tibia- Necrosis, Ulcer of the Leg". — Portion of a tibia — macerated, illustrating the above. A large loose sequestrum near the lower end has been partially surrounded by new bone. Near the upper end of the preparation there is a flattened enlargement, with an irregular and somewhat porous surface. This has probably formed the base of a chronic ulcer of the skin, secondary to the bone disease. B. C. i. 5. M. 34. 6. 127. Acute Suppurative Osteo-myelitis of the Tibia- Necrosis. — Eight tibia and fibula — injected, muscles removed, and in spirit, illustrating the above. A sequestrum removed from the tibia is fixed by a thread to the fibula. A bridge of bone formerly lay over the large newly formed bone cavity, in which the necrosis was lodged. This bridge was cut across by the surgeon in order to extract the necrosis. The vascularity of the new bone is shown by the injection. The disease apparently had extended close to, if not into, the knee- joint. G. C. 1056. Figured in Russell on "Necrosis," plate ii. page 183. Presented by Professor James Russell. 6. 128. Acute Suppurative Osteo-myelitis— Necrosis.— Pre- paration apparently of a tibia, illustrating the above. There are two separate sequestra. They are only partially surrounded by a case of new bone, which shows cloacae at some places and irregular gaps and apertures at others. B. C. I. 5. M. 39. 6. 129. Acute Suppurative Osteo-myelitis of the Tibia- Necrosis. — Lower three-fourths of a left tibia — macerated, illustrating the above. There are two large sequestra, partially surrounded by a 258 Diseases of Bone. case of new bone. This is deficient along the front, and not well formed anywhere. The surface of the sequestrum has been blackened. E. C. i. 5. M. 38. 6. 130. Acute Suppurative Osteo-myelitis of the Tibia— NeCFOSis. — Right tibia — macerated, illustrating the above. There has been more or less complete necrosis of the shaft from end to end. The sequestrum has been separated from the remains of the original bone, and new periosteal bone has been developed round it. The new shell, however, is so imperfect that the greater part of the sequestrum is exposed. There is an oval aperture with rounded margins low down on the inner side of the new case, tlie nature of which is obscure ; possibly it was made by a surgeon. B. C. i. 5. M. 42. 6. 131. Acute Suppurative Osteo-myelitis of the Tibia- Necrosis, Imperfect Regeneration, Enlargfementofthe Fibula. — Right fibula and portions of tibia of a young person — macerated, illustrating the above. "The disease had affected the leg for nine years." Amputation was performed with success. " The lower part of the tibia had become .soft and spongy ; the periosteum was much thickened at the diseased parts ; there was extensive ulceration of the soft parts." A portion, nearly three inches in length, is wanting from the lower end of the shaft of the tibia. The upper fragment of the tibia is for the most part irregular, but the surfaces are smoothed over. The upper end of the lower fragment is much rarefied. The fibula is much thickened, especially near the middle, by irregular deposits of bone on the surface. Opposite the deficiency in the tibia, however, the surface of the fibula is rarefied and has been partly absorbed. Probably in this case there has originally been septic osteo- myelitis and necrosis, followed by a foul-spreading ulcer. This Necrosis from Pus-forming Organisms. 259 might have at first caused the enlargement of the fibula, and afterwards extended into it, while its presence would account for the localised destruction of the tibia. G. C. 1482. Presented by Professor J. W. Turner and A. Watsox, F.R.C.S.E. 6. 132. Acute Suppurative Osteo-myelitis of the Tibia- Necrosis. — Lower two-thirds of a left tibia — macerated, illus- trating the above. This specimen is described in the General Catalogue as belonging to a person aged 14, and in the former printed Catalogue as belonging to an old person. From the general appearance of the specimen, and from the union of the lower epiphysis, the latter statement is evidently the correct one. There has been necrosis, apparently, of almost the whole shaft, but the sequestrum, although pitted and eroded, has not been completely separated at the lower end. Along the inner and back part_there has been a development of new bone, which is adherent to portions of the original shaft. G. C. 1144. 6. 133. Acute Suppurative Osteo-myelitis of the Fibula — Necrosis. — Lower fourth of a tibia — macerated, illustrating the above. Lower necrosed portion wired to the part above. The lower end has necrosed and has been partly absorbed. The vipper portion shows a considerable crust of ncAV periosteal bone on its surface. W. C. G. 61. (c.) Sequestra, or portio^is of dead heme which hare been separated from the living by natural 2)roccsses. 6. 134. Sequestrum, after Acute Suppurative Osteo- myelitis of the Ulna. — Upper three-fourths of an ulna which formed the above. The patient was a little Cashmir girl. This piece of bone was removed by Dr. A. Neve in May 1887, after the acute symptoms had subsided. She made an excellent recover}', and had a useful elbow- joint. 260 Diseases of Bone. At the upper end the necrosis has extended to the epi- physes, but at the lower end the line of separation has been a little above the epiphysis. G. C. 3308, Presented by A. Neve, F.R.C.S.E., Cashmir. 6. 135. Sequestrum, after Acute Suppurative Osteo- myelitis of the Humerus.— Upper end of the shaft of the humerus of a boy, illustrating the above. The boy was a comb-maker, and one of the combs which he made after his recovery is mounted along with the specimen. The necrosis has involved the entire thickness of the upper end. The line of separation is somewhat oblique. G. C. 3355. 6. 136. Sequestrum, after Acute Suppurative Osteo- myelitis of the Femur. — Portion of the lower end of the shaft of a young person's femur, illustrating the above. The flat popliteal area, and almost the entire circumference above it, has become detached. The greater part of the surface is eroded, except at the lower end. The separation has been partly from within and partly from without. G. C. 223. 6. 137. Sequestrum, after Acute Suppurative Osteo- myelitis of the Tibia. — Portion of the upper end of the shaft of a tibia, illustrating the above. The sequestrum comprises cancellated as well as compact tissue. The separation has taken place chiefly from within. G. C. 202. 6. 138. Sequestrum, after Acute Suppurative Osteo- myelitis of the Tibia. — Portion of the upper end of the shaft of a young child's tibia, illustrating the above. The sequestrum is irregular at the point of separation below, but higher up it is smooth, and has comprised the entire thickness of the bone, G. C. 283. Sequestra after Septic Necrosis. 261 6, 139. Sequestrum, after Acute Suppurative Osteo- myelitis of the Tibia.— Large part of the shaft of a child's tibia, illustrating the above. The whole thickness of the shaft has come away^ with the exception of a small strip at one side, where the irregularity of separation is easily seen. The surface is smooth at the margins, so that the separation must have been from within. G. C. 223. b. 6. 140. Sequestrum, after Acute Suppurative Osteo- myelitis of the Tibia.— Large portion of the shaft of a tibia, illustrating the above. Nearly the entire thickness of the bone has become necrosed. The fragment is very irregular, and is eroded on both its outer and inner aspects. G. C. 223. a. 6. 141. Sequestra, after Acute Suppurative Osteo- myelitis.— Two portions of the shafts of long bones — probably of tibia, illustrating the above. The lower and smaller piece is smooth, except at the margins and within, where it has been separated. The larger one, from an older person, has patches of rarefaction on its surface, as if it had been inflamed before it had finally necrosed. It shows the usual characters of pitting and irregularity at its margin and on the upper irregular prolongation. B. C. I. 5. M. 36. 6. 142. Sequestrum, after Acute Suppurative Osteo- myelitis of the Tibia. — Portion of the shaft of a tibia of a young person, illustrating the above. The entire thickness has died at one place. The surface is slightly pitted in front, and the margins are irregular. G. C. 222. 262 Diseases of Bone. 6. 143. Sequestrum, after Acute Suppurative Osteo- myelitis of the Tibia.— Portion of the shaft of the tibia of a child, illustrating the above. There is great irregularity of the outer surface, and at the margins of separation. The nutrient canal is well seen in the interior of the bone. G. C. 1008. 6. 144. Sequestrum, after Acute Suppurative Osteo- myelitis of the Tibia. — Large portion of the shaft of a tibia, illustrating the above. The specimen represents nearly the entire thickness of the shaft at one place, with a varying proportion, mostly of the front at other places; the bone is greatly eroded and pitted, not only at the margins and on the internal surface, but over the greater part of the outer surface as well. G. C. 1170. Fresentcd by Professor James Russell. 6. 145. Sequestra, after Acute Suppurative Osteo-myelitis. — Two portions of the shafts of long bones, illustrating the above. The longer piece shows the usual characters of a sequestrum, after suppurative inflammation. The other is very irregular, and has some new bone growth upon it. These specimens are described in the M.S. Catalogue as "sequestrum, removed from tibia of a boy, aged 12 years." This probably refers to the longer piece only. G. C. 796. Presented by Sir George Ballingall. 6. 146. Sequestrum, after Acute Suppurative Osteo- myelitis of the Tibia. — Portion of the shaft of a tibia^ illustrating the above. "The patient afterwards did well." Sequestra after Necrosis from Pus-forming Organisms. 263 The bone shows the mark of a trephine. The irregularity of the margins is characteristic of the natural process of separation. G. C. 1162. Presented by Professor James Russell. 6. 147. Sequestrum, after Acute Suppurative Osteo- myelitis.— Portion of the shaft of a long bone, illustrating the above. There is great irregularity on every aspect. G. C. 3354. 6. 148. Sequestrum, after Acute Suppurative Osteo- myelitis of the Tibia. — Portion of the shaft of a tibia, illustrating the above. The separation has been mostly from without. G. C. 1174. Presented by Professor James Russell. 6. 149. Sequestrum, after Acute Suppurative Osteo- myelitis of the Tibia. — Two portions of cancellous tissue said to be from the tibia of a boy 1 2 years of age. A cast of the leg and foot, after cure in this case was completed, was presented to the Museum along with this specimen, but it cannot now be traced (1893). G. C. 1786. 6. 150. Sequestra, after Acute Suppurative Osteo- myelitis.— Eleven portions of the shafts of long bones, illustrating the above. They show the usual characters. One piece has evidently followed amputation. The others seem, like the previous specimens, to have been idiophic. G. C. 1170. Presented by Professor James Russell. 264 Diseases of Bone. 6. 151. Sequestpum, after Acute Suppurative Osteo- myelitis of the Internal Cuneiform Bone.— Remains of an internal cuneiform bone which formed the above. The patient was a badly nourished boy, aged lo. After a slight strain of the foot, he was seized with sudden and intense pain in it, which terminated in suppuration. About a fortnight after this, when the resulting sinus was explored, this bone was found loose. The parts were scraped and the boy made a slow recovery. The surface of the bone is eroded and irregular. G. C. 3453. Prcseyited by Charles W. Cathcart, F.R.C.S.E., 1892. 6. 152. Sequestrum, after Acute Suppurative Osteo- myelitis of Lower Jaw. — Portion of ramus and condyle of a lower jaw, forming the above. Part of the condyle and the separated margin is rarefied and irregular. G. C. 1171. Figured in Russell on "Necrosis," plate v. fig 4. Presented by Professor James Russell. 6, 153. Sequestrum after Acute Suppurative Osteo- myelitis of the Lower Jaw. — Portion of the right half of the body of a lower jaw, which formed the above. The whole thickness of the bone has come away at the alveolar border, but only the outer plate below. The usual irregularity at the separated margins is seen. G. C. 1172. Figured in Russell on " Necrosis," plate v. fig. 5. Presented by Professor James Russell. 6. 154. Sequestrum after Acute Suppurative Osteo- myelitis of the Lower Jaw.— Portion of a lower jaw, which formed the above. "Andrew S., 12th July 1824, aged 62, a wright. The left cheek, especially of whole of left side of lower jaw, presents a rounded equable swelling, which on examination consists of the swollen glands Sequestra after Necrosis from Pus-forming Organisms. 265 and of the integuments as well as of the body of the jaw, which is much enlarged. There is considerable purulent foetid discharge from an opening below the alveoli of first molar, where the probe can be introduced for an inch amongst carious bone. All the molar teeth and their alveoli are carious, and there is an ulcerated state of the gums in general. The affection commenced eleven weeks back similarly to toothache, became much swelled, burst and discharged matter three weeks afterwards into the mouth as above described. Has occasionally very severe pains in the" affected part. ' ' His health has suffered much. Bowels have been very loose ; pulse rather quick. Tongue foul ; has poulticed the part frequently. ' '16^^. — Health much improved. Tongue clean. Bowels still rather loose. External tumour much less, but a large mass of the bone is mov- able, along with the alveoli of all the molar teeth. "25th. — A piece of the lower jaw-bone, of two inches in length and half-aninch in breadtli, including the canal for the artery and nerve, was extracted yesterday with great ease and little pain. The cavity left was stuffed with dry lint. There is yet considerable swelling of the cheek. Health pretty good. " 27ih. — Another large plate of bone extracted yesterday. Granula- tions look healthy. In other respects he is quite well." 28th. — Dismissed cured. The specimen shows the usual irregularity at the separated margins. The groove which formed part of the dental canal is clearly seen. G. C. 991. 6. 155. Sequestrum, after Acute Suppurative Inflamma- tion of the Alveolar Border.— Portion of the jaw of a child, which formed the above. The separated piece contains two milk molar teeth. G. C. 721. {d.) Bepair after the separation of sequestra. 6. 156. Reparation of Tibia after Removal of a Seques- trum.— Sequestrum and right tibia in section — macerated, to illustrate the above. The patient, a boy, was aged eight years when the sequestrum was removed. The tibia from which it had been taken was obtained six years afterwards, i.e. when he had reached the age of fourteen. 266 Diseases of Bone. The sequestrum shows the usual characteristics. The new- tibia is curved forward, and is thickened, especially on its inner surface and behind. There is a well-marked medullary cavity, partially occupied by cancellated tissue, and with compact walls, which are thick and dense, especially about the middle. The thick part is the seat also of the bend, and this was doubtless the place from which the sequestrum came. Probably the bone yielded by being used before it was solid. The thickening may have followed afterwards from strain. Compare the rickety tibia, K"o. 6. 38. G. C. 1143. Presented hy Professor James Russell. 6. 157. Reparation of Tibia after Removal of a Seques- trum.— Sequestrum and left tibia in section — macerated, illus- trating the above. The specimen was obtained eighteen years after the removal of the sequestrum. The sequestrum, which has consisted of the entire thickness of the shaft, over the greater part of its extent shows the usual characteristics. The new tibia is somewhat bent, but in addition is very irregular. New bone has been thrown out on all sides, but especially over the shin, where there is also a shelf- like projection towards the outer side. The medullary canal has been filled in, if a new one was ever formed. Ai each end there is a cavity in the cancellous tissue, but these may have been made in preparing the specimen. A large ulcer has probably remained after the sequestrum was removed, and having become chronic, has produced secondary changes upon the newly formed tibia. G. C. 1142. Presented by Professor James Russell. B. Where the Organisms have reached the Bone through "Wounds in the adjacent Soft Parts. a. Disease in bone secondary to ulcers. 6, 158. Ulcer of the Leg" extending down to the Bone.— Invasion of Bone from Ulcers. 267 Section of a tibia — injected with vermilion and in spirit, to illustrate the above. The granulating margin of an ulcer of the soft parts has been left surrounding an area of the bone, which has evidently formed its base. Part of this area is covered by imperfect granulations, part is bare, and part shows a development of new gponge-like bone. The section shows the compact tissue beneath the ulcer to have been thickened by a deposit on the surface. B. C. I. 5. M. 3. 6. 159. Ulcer of the Leg- extending- down to the Bone.— Section of the previous specimen— macerated, to illustrate the above. The surface of the bone which lay underneath the granula- tions on the floor of the ulcer is rough and porous. It has been a new development, but has apparently been invaded by the ulcer as it became deeper. B. C. i. 5. M. 3. 6. 160. Invasion of the Tibia by an Ulcer of the Leg*.— Portions of a tibia — macerated, to illustrate the above. Over an area of about three inches in length the bone is hollowed out, and is porous on the surface, while irregular bone has been developed round about. Apparently this has been caused by an ulcer of leg extending downwards into the bone. B. C. I. 5. M. 17. 6. 161. Invasion of the Tibia by an Ulcer of the Leg".— Portion of an injected right tibia. Soft parts removed, except those which formed the ulcer — in spirit, to illustrate the above. An area of the bone has been exposed on the floor of the ulcer, and a section has been made to show the relations of 268 Diseases of Bone. this piece to the rest of the bone. The bare patch has been surrounded by vascular granulations, which have formed a trench round it. It has thus evidently been necrotic, and in process of separation. Beneath the bare piece there has been a small abscess in the cancellated tissue. G. C. 1052. 6. 162. Invasion of the Tibia by an Ulcer of the Leg*.— Section of portion of the previous specimen — macerated, to illustrate the above. During maceration the bone was accidentally broken, and has been wired together. The surface of the bare, necrotic piece of bone is porous. The groove surrounding it is well shown. Beyond the groove the very porous character of the bone, which during life was covered^by granulation tissue, should be noted. This part merges off above into new periosteal bone growth. G. C. 1&52. h. Where the chief changes are in the form of rarefaction. 6. 163. Rarefaction of the Ulna after Compound Fracture. — Upper end of a left ulna — macerated, illustrating the above. The lower end of the fragment is very irregular,, and is partially absorbed. The surface is covered irregularly with periosteal new bone, while at places on the front the interior is seen to be rarefied and absorbed. This has probably been the result of a bad compound fracture. B. C. i. 5. M. 96. 6. 164. Rarefaction and Necrosis of Femur after Ampu- tation.— Portion of a femur, removed from a stump — macerated, to illustrate the above. One portion of it is dead, and has been in process of separation. The rest is opened out and irregular, with some periosteal new bone on the surface. The rarefactive change, if anything, preponderates. F. P. C. 552. Presented by Professor James Russell. Caries from Septic Wounds. 269 6. 165. Rarefaction of Femur after Compound Fracture, — Lower end of a right femur — macerated, to illustrate the above. The broken surface is opened out, and some new bone has been developed near. At the back, near the upper end, there are two distinctly punched-out holes, possibly due to absorption by granulations. F. P. C. 397. 166. Rarefaction of the Tibia after Compound Fracture. • — Section of the distal end of a left tibia — macerated, to illustrate the above. There has been absorption of the upper end, with develop- ment of new bone on the adjacent surface, This has probably been a case of compound fracture, with prolonged suppuration. B. C. I. 5. M. 81. 6. 167. Rarefaction of the Shaft of a Tibia, with some new Periosteal Growth from some Septic Condition. — Right tibia — macerated, illustrating the above. Over nearly the whole of the shin surface the bone is rarefied and rough. New bone has been thrown out on the posterior surface, with appearances very suggestive of septic inflammation. The anterior and posterior parts of the articular surface have apparently been attacked. B. C. i. 5. M. QQ. 6. 168. Rarefaction of the Shaft of the Femur from Sepsis after Amputation. — Portion of the shaft of a femur — macerated, illustrating the above. Septic inflammation must have followed the amputation. Some periosteal bone has been thrown out for several inches above the lower end. The surface of the bone all over is opened out, evidently from absorption round the blood-vessels. This is a good example of septic rarefactive ostitis, or what may be called a septic form of caries. B..C. i. 5. M. 29. 270 Diseases of Bone. 6. 169. Rarefaction of Frag-ments of the Fibula after Compound Fracture. — Lower half of a fibula, portions wanting — muscles cleaned off — dried, to illustrate the above. About three inches of the bone have disappeared. The margins of the remaining fragments are rarefied, and a crust of new periosteal bone has been developed near. These changes have probably been caused by a severe compound fracture. G. C. 1144. Presented hy Professor James Russell. 6. 170. Absorption and Irreg-ular Outgrowth of the Tibia after Compound Fracture. — Lower end of a right tibia — macerated, illustrating the above. The upper end of the fragment is atrophied and smoothed oflf at some places, while at others it shows irregular outgrowths. The case has apparently been one of compound fracture in process of healing by fibrous tissue. B. C. i. 5. M. 80. c. AVhere the chief changes are in the form of enlargement. 6. 171. Periosteal Thickening following Compound Frac- ture.— Upper portion of a right fibula, after fracture — macerated, showing the above. At the broken part there is some irregularity from absorp- tion, and beyond that a crust of new periosteal bone has developed. This is probably the result of a compound fracture. B. C. I. 5. M. 87. 6. 172. Rarefaction and Periosteal Crust from a Septic Wound. — Lower half of a right fibula — macerated, illustrating the above. There are marks of rarefactive ostitis at the malleolus, and Necrosis from Sciatic Wounds. 271 a crust of new periosteal bone is seen in patches up the shaft. The cause of the septic condition is obscure — possibly a compound fracture of the tibia. B. C. i. 5. M. 25. d. Where the chief changes are in the form of necrosis or death of a palpable portion. (a.) Where the dead -piece has been in process of separation, 6. 173. Septic Osteo-myelitis following" Compound Frac- ture — Necrosis. — Section of an injected tibia — muscles dissected off and in spirit, illustrating the above. The patient died of erysipelas and tetanus about two months after the fracture. " l!^ecrosis took place, and the limits of the dead portion are marked by bristles." The fragments have not been in good position. The broken ends are united by fibrous tissue. There is considerable thickening round about. B. C. i. 1. M. 45. 6. 174. Septic Osteo-myelitis and Necrosis following- Gun- shot (Compound) Fracture.— Portion of the shaft of a femur — macerated, illustrating the above. The wound was received at the battle of Waterloo. The fracture has been comminuted, and the broken ends are irregular. The surface of the dead pieces is smooth and unchanged. There are marks of rarefactive ostitis beyond the dead parts, and a trench separates them from the living bone in the usual way. F. P. C. 218. Presented hy Professor John Thomson. 6. 175. Septic Osteo-myelitis following- Gunshot (Com- pound) Fracture. — Portion of the shaft of a femur, illustrating the above. The wound was received at the battle of Waterloo. 272 Diseases of Bone. The small necrosed piece is in process of separation as in the previous case. Beyond the area of rarefaction there is a slight crust of new periosteal bone. F. P. C. 219. Presented hy Professor John Thomson. 6. 176. Septic Osteo-myelitis following" Gunshot (Com- pound) Fracture. — Portion of the upper part of a right femur, illustrating the above. The wound was received at the battle of Waterloo. This specimen shows essentially the same features as the last, but with more new periosteal bone above the line of demarcation. F. P. C. 220. Presented by Professor John Thomson. 6. 177. Septic Osteo-myelitis and Necrosis following* Com- pound Fracture. — Sections of part of a femur — macerated, illustrating the above. The smooth dead bone at the seat of fracture has been in process of separation. The rarefaction involved thereby has occurred mostly on the outer surface, but it is visible also on the medullary aspect. G. C. 1159. Presented by Professor James Russell. 6. 178. Septic Osteo-myelitis and Necrosis following" Amputation. — Portion of the shaft of a femur after amputa- tion— macerated, illustrating the above. The sawn end has necrosed, and has been in process of separation. Immediately above the necrosed piece an imper- fect collar of new periosteal bone has been formed, and the surface of the rest of the shaft shows the effects of rarefactive ostitis, combined with a limited amount of new periosteal bone growth. G. C. 1158. a. Presented by Professor James Russell. Necrosis from Seijtic Wounds. 27 o 6. 179. Septic Osteo-myelitis and Necrosis following- Compound Fracture. — Lower two-thirds of the shaft of th left tibia of a boy (epiphysis wanting) — macerated, illustrating the above. There is a necrosed portion at the upper end in process of separation. Some new periosteal bone has been thrown out on the shaft below. B. C. i. 5. M. 24. 6. 180. Septic Osteo-myelitis and Necrosis following- Compound Fracture. — Greater part of a broken tibia — fragments wired together — and lower end of fibula — macerated, illustrating the above. The greater portion of the upper fragment of the tibia is irregularly pitted on the surface, and apparently has been in process of separation from the rest. A mass of irregular bone,, chiefly of new formation, lies on the outer side between the two^ fragments. Xear the seat of fracture the lower fragment has new bone developed on its anterior and inner aspects, but not behind. The fragment of the fibula shows an area of necrosis- at the seat of fracture, and a slight periosteal crust below. Figured in Russell on " Necrosis," plate vi. G. C. 1184, 6. 181. Septic Osteo-myelitis and Necrosis of the Humerus after Amputation— Pyaemia — Death.— Sections of the upper half of a humerus — partially macerated, and in spirit, to illustrate the above. The patient was a man aged 21, whose forearm forms the specimen No. 6. 111. He died of pyremia after amputation above the elbow. The greater part of the shaft has necrosed, and over the surface of this part, but separate from it, a thin shell of new periosteal bone has been formed. It may be noted that the granulations on the deep or inner surface of this new shell have attacked the outer surface of the necrosed shaft. The upper end of the shaft is rarefied, and has evidently been 274 Diseases of Bone. infiltrated with pus, and the head has necrosed and formed several separate fragments. This specimen illustrates septic caries and necrosis of the cancellated tissue, with necrosis also of the compact tissue. G. C. 982. 6. 182. Septic Osteo-myelitis and commencing' Necrosis after Scalp Wound. — Calvarium (with permanent frontal suture) — macerated, illustrating the above. A large, smooth area of what seems to have been necrosed bone in an early stage of separation is seen on the front, chiefly on the left side. There is a shallow line of demarcation marked off round it. G. C. 912. 6. 1 83. Septic Osteo-myelitis and commencing Necrosis of the Skull after severe Scalp Wound.— Skull-cap- macerated, illustrating the above. "This man had his scalp torn oif the skull. It was replaced. Suppuration under the scalp followed, and he died finally of suppura- tion of the membranes of the brain." The dead portion is smooth, and round it the bone is porous from the enlargement of vascular channels. On the interior, especially along the middle line, marks of increased vascularity are visible. B. C. i. 2. M. 14. e. 6. 184. Septic Osteomyelitis and Necrosis of the Skull, following" a Scalp Wound.— Left half of a calvarium— macerated, illustrating the above. There is a small scale of necrosed bone in process of separation upon the front of the parietal bone below the temporal ridge. F. P. C. 477. Presented by Professor James Russell. Necrosis from Septic Wounds. 275 6. 185. Septic Osteomyelitis and Necrosis, following Gun- shot (Compound) Fracture of the Ribs.— Portion of a chest Avall — in spirit, illustrating the above. The ribs are broken and greatly comminuted, and some portions have apparently been necrotic. The pleura is thick- ened and covered with lymph. A small portion of lead was found in the soft parts, thus giving a clue to the possible cause of the condition. G. C. 3356. (6.) Where the dead piece has become loose, but has remained in iwsition, and has acted as a source of irritation. 6. 186. Septic Osteomyelitis and Necrosis of the Tibia following Fracture (Compound?).— Lower end of the left femur of a child, along with the tibia and fibula — partially cleaned and dried, to illustrate the above. "The injury was received on 1st February 1805, and the limb was removed on 10 th October in that year. The process of regeneration being exceedingly slow, amputation was performed in order to save the patient." The upper two-thirds of the shaft of the tibia is smooth, and has been separate from the epiphysis and adjacent soft parts. Its lower end is concealed by a shell of new bone in which there is a cloaca. The sequestrum shows a sharp margin at the back just above the level of the new shell. The fracture has therefore probably been at the lower end. The texture of the lower end of the femur is thin and light. G. C. 1178. Presented by Professor James Russell. 6. 187. Septic Osteo-myelitis, Necrosis, and Chronic En- largement of the Femur following Amputation.— Portion of the shaft of a femur— macerated, illustrating the above. There is a large deficiency at the back and lower end of 276 . Diseases of Bone. the preparation, from -which a sequestrum has apparently been removed. The front of the preparation is covered by an irregular crust of new bone. G. C. 1158. Presented by Professor James Russell. 6. 188. Septic Osteo-myelitis, Necrosis, and Chronic En- largement of the Femur following- Amputation.— Portion of the shaft of a femur — macerated, illustrating the above. A graveyard fragment, probably a portion removed in a secondary amputation. There is much irregularity of the surface, and a deficiency exists at the lower end and in the interior, as if due to the removal of a sequestrum. The upper end of the preparation has been sawn across. B. C. i. 5. M. 63. 6. 189. Septic Osteo-myelitis, Necrosis, and Chronic En- largement of the Tibia following Amputation.— Portion of the shaft of a right tibia — macerated, illustrating the above. Probably a portion removed in a secondary amputation. There is a rough periosteal crust near the lower end, which is itself irregular, and shows a deficiency extending into the interior — probably due to the removal of a sequestrum. G. C. 1133. Presented by Professor James Russell. 6. 190. Septic Osteo-myelitis, Necrosis, and Enlargemen of the Tibia following Compound Fracture.— Lower end of a right tibia — macerated, illustrating the above. At the upper irregular end of the preparation there is a small white piece of necrosed bone lying between an irregular mass of Necrosis from Septic Wounds. 277 new bone and a rarified portion of the original shaft. Much new periosteal bone has been thrown out on the surface all round. The case has probably been one of compound fracture. W. C. G. 58. 6. 191. Septic Osteo-myelitis, Necrosis, and Enlapgement of the Tibia following- Amputation. — Upper third of a right tibia — macerated, illustrating the above. A considerable portion of dead bone is seen running up upon the inner side, and its lower end has been part of a sawn surface. It has been separated, but has been fixed in position by partial development of new bone round it. The rest of the shaft of the tibia shows new bone growth on the surface and absorption within. Probably two other large pieces of necrosed bone have been removed from the gaps on the front and outer sides. B. C. I. 5. M. 32. 6. 192. Septic Osteomyelitis, Necrosis, and Enlargement of the Tibia following" Amputation. — Upper three-fourths of a right tibia — macerated, illustrating the above. There is a partial development of new bone on the surface, with a deficiency in front and on the inside, from which a sec[uestrum has probably been removed. The exposed portions of the original shaft are rarefied. G. C. 985. 6. 193. Septic Osteo-myelitis, Necrosis, and Enlargement of the Femur following Amputation.— Greater portion of the shaft of a femur — macerated, illustrating the above. The bone has been greatly thickened, and the surface presents the usual characters of new periosteal bone formation. There are four cloacal apertures, through some of which dead pieces of bone can be seen. A necrosed fragment has evidently been removed from the centre of the lower end and from the front of the upper end. B. C. i. 5. M. 30. 278 Diseases of Bone. 6. 194. Septic Osteo-myelitis, Necrosis, and Enlarg-ement of the Femur following" Amputation.— Greater portion of the shaft of a femur — macerated, illustrating the above. The bone has been very much thickened, and the surface is unusually irregular. There are numerous cloacal apertures, and several pieces of dead bone are seen through them. The disease has extended upwards nearly to the small trochanter. B. C. I. 5. M. 31. (c. ) Sequestra — or portions of dead hone which have been separated frovi the living by nattiral processes. 6. 195. Sequestrum of the Shaft of a Tibia after Septie Osteo-myelitis following" Amputation.— A large portion of necrosed bone, apparently from the tibia of an adult. The surface shows the usual pitting produced by granula- tions ; but, in addition, the inner side shows some borings, apparently produced artificially. A node-like irregularity is seen towards the upper end of the specimen. W, C. G. 54. 6. 196. Sequestrum of Femur after Septic Osteo-myelitis following" Amputation for Gunshot Fracture.— This was one of the cases treated after the Battle o.f "Waterloo. Except at the sawn surface, which is smooth, the specimen is very irregular, and its surfaces are pitted and eroded on both inner and outer aspects. Figured in Hennen's " Principles of Military Surgery," 1st edition, plate iv. figure 3. F. P. C. 224. Presented by Professor John Thomson. 6. 197. Sequestrum after Septic Osteo-myelitis following- Amputation, Seqitesti^a after Necrosis from Septic Wounds. 279 "A very considerable portion more came away, but it was so soft and pliable that it would not preserve." This specimen shows characters similar to the last. G. C. 1157. 6. 198. Sequestrum formed by a First Phalanx from Septic Osteo-myelitis due to Whitlow. It was from a left index finger, and was ' ' removed by operation in a case of paronychia." The specimen is partly eroded on the anterior surface, and has a slight crust of new bone upon the back. G. C. 1132. Presented by Adam Huntek, F.R.C.S.E. 6. 199. Sequestrum of Lower Jaw due to Septic Osteo- myelitis following" Injury.— Greater portion of the right half of the body of the lower jaw of a boy, and a piece of clay pipe stem, to illustrate the above. The boy was smoking a cutty pipe. His father in trying to knock it out of his mouth drove the stem into the jaw, where a portion broke off and remained unobserved. Inflammation and suppuration supervened, and eventually the large sequestrum shown became loose. Professor James Miller removed it, and found within it the piece of pipe stem which is now mounted along with it. The specimen shows at many places the irregularities associated with the process of separation. G. C. 3187. Presented by A. G. Miller, F.R.C.S.E. 6. 200. Sequestrum from the Skull due to Septic Osteo- myelitis following" Fracture (Compound ?). The bone shows the mark of a trephine. Both tables are smooth on the inner surface, but the one has been more ex- tensively absorbed than the outer. The margins of both plates are very irregular, and the diploe has been absorbed for some "way between them. F. P. C. 482."^ Presented by John Thomson, F.R.C.S.E. 280 Diseases of Bone. 6. 201. Sequestrum from the Skull due to Septic Osteo- myelitis following- Injury. The bone was " denuded of periosteum by accident and subsequently thrown off." The bone is exceedingly irregular and eaten out by the action of granulations. G. C. 1168. 4. * Infiammation of Bone 'produced hy the Tuhercle Bacillus. a. Where the chief changes are in the form of rarefaction and absorption, i.e., a tubercular form of caries. 6. 202. Tubercular Disease of Carpal and Metacarpal Bones. — Section of part of the right hand of a woman — injected, and in spirit, showing the above. Mary A., let. 26, Shetlander, had a tubercular appearance and family history. Six months before coming to Hospital she liad "acute rheumatism " (tuberculosis ?) which did not affect the joints of the right wrist, although it attacked almost all her other joints. She believed she had twisted this wrist while turning in bed when suffering from the "rheumatism." The wrist and hand gradually became swollen, painful, and unnaturally movable. Fluctuation ensued. Amputation was performed above the wrist. A week later she had severe pain in her head. There was no phthisis, but death occurred shortly afterwards from general tuberculosis. No post-mortem examination was obtained. There are caseous deposits in many of the carpal bones and in the bases of the metacarpals. Some of these centres are surrounded by a vascular area, and in some cases the caseation has spread from one adjacent bone to another. At some places the bones are softened, vascular, and broken down. In many places the cartilage has disappeared, having been chiefly attacked from within. The non -vascular portion of the radial side of the unciform consists of hard dense bone, in the others the non-vascular portion is caseous and soft. G. C. 3072. Presented hy A. G. Miller, F.R.C.S.E., 1889. 6. 203. Tubercular Disease of the Sternum.— Sternum of a * See series 7 for other examples of tubercular disease of bone. Tubercular Caries. 281 negro, with portion of overlying skin — in spirit, to illustrate the above. A sinus shown in the skin communicated " with a vomica of the lungs." The bone seems to have been greatly destroyed and to have been replaced by granulations. B. C. I. 5. M. 10. 6. 204. Tubercular Disease of the Sternum.— Sternum- macerated, illustrating the above. The manubrium and lower portion of the body is exten- sively absorbed and opened out, apparently by tubercular inflammation. B. C. i. 5. M. 11. 6. 205. Tubercular Disease of the Sternum.— Manubrium and part of the body of a sternum — macerated, illustrating the above. An abscess, probably tubercular, "had formed beneath the sternum." The bone is lightened and partially absorbed, especially at the posterior and right margins. G. C. 656. 6. 206. Tubercular Disease of the Clavicle.— Left clavicle — macerated, illustrating the above. Tliere is a large irregular erosion on the upper surface, about the middle. The walls of this excavation are rarefied, and the bone in front is reduced to a mere perforated shell. There is comparatively little new bone formation round this eaten-out part, but at the outer end of the clavicle some may be observed. Probably this has been a case of tubercular dis- ease. W. C. G. 26. 6. 207. Tubercular Disease of Radius and Ulna.— Eight radius and ulna — macerated, illustrating the above. 282 Diseases of Bone. The upper end of the radius shows patches of absorption passing into the interior and through to the other side without any deposit of new bone on the surface. The ulna shows a similar condition at two places, one at the upper end on the inner side, and another at the back of the shaft. Tubercular disease seems the most probable cause of this condition. G. C. 994. 6, 208. Tubercular Disease of the Femur.— Upper end of a right femur — macerated, illustrating the above. There are large patches^ of absorption and rarefaction on the back of the shaft and below the lesser trochanter. The surface of the bone is also somewhat rarefied, especially to- wards the lower end of the specimen. Possibly this has been a case of tubercular disease. F. P. C. 387. b. "Where the chief changes are in the form of absorption and enlargement. 6. 209. Tubercular Enlargement of the Humerus.— Lower end of the shaft of a humerus, portion cut out to show the interior — macerated, illustrating the above. The interior of the bone is rarefied and hollowed out, and there is a shell of variable thickness on the surface, giving the appearance of expansion. The shaft of the bone above the diseased part has an exceedingly thin shell, and the medullary canal communicates with the hollow below. This condition was formerly called " spina-ventosa." G. C 1152. Presented by Professor James Russell. 6. 210. Tubercular Enlarg-ement of the Lower End of the Femur. — Lower end of a left femur, with anchylosed patella — macerated, illustrating the above. The articular surfaces are very irregular, and one is par- tially deficient. The interior is rarefied and partially absorbed^ Tubercular Enlai^gement. 283 and there is some new bone on the surface. This has evidently been a case of tuberculosis of the knee-joint, which has healed with extensive distortion. It was formerly described as " spina- ventosa." There is a peculiar crack in front of the specimen, for which it is difficult to account. As there is some new bone over and near it, it may have been caused in an attempt to straighten the limb. F. P. C. 650. Presented by Professor John Thomson. 6.211. Tubercular Enlargement of the Lower End of the Tibia. — Lower end of a right tibia — macerated, illustrating the above. Several apertures seen in the expanded shell communicated in the recent condition with an abscess in the soft parts. There has been enlargement on the surface, and absorption within. The interior of the bone has an irregularly scooped- out appearance. The disease has probably been tubercular. W. C. G. 27. 6. 212. Tubercular Abscess and Enlargement of the Lower End of the Tibia. — Section of part of a left foot and lower end of the tibia — macerated, illustrating the above. ' ' Mrs A. , aged 43, a delicate, nervous woman, suffered from suppurating cervical glands several years ago ; her family and personal history was other- wise good. Three years ago pain began in the left loin, and extended down gradually to left ankle, and remained there for three months. It subsided completely, but returned in a few months, as result of a blow on the ankle. An abscess formed and was opened, and healed after discharging for a few months. The abscess opened again, and was relieved by carbolic acid fomentations, but returned one month before admission to the Infirmary. The patient was able to walk until within a week of admission, though with difficulty. The large abscess cavity of tibia was opened into, and caseous matter was scraped out. In fourteen days pain spread to ankle, and amputation became necessary." The specimen shows the abscess in the tibia laid open. The walls at the bottom are covered by bare and dead (non- 284 Diseases of Bone. vascular) bone, higher up vascular granulations are seen, and still higher caseous material lines these granulations. The disease had spread high up in the tibia near to the upper thread, i.e. in the second section of tibia which is attached to the chief specimen. G. C. 2834. Presented by P. H. Maclaren, F.R.C.S.E. 6. 213. Tubercular Abscess and Enlargement of the Lower End of the Tibia. — Lower end of fibula and section of tibia from the previous case — macerated, to illustrate the above. The cavity in the tibia is lined by rarefied bone. On the outside there is much new bone formation. The fibula also shows new periosteal bone on the surface, but the cancellated tissue exposed below is not the result of disease, but from an accident during maceration. G. C. 2835. 6. 214. Tubercular Enlargement of Shaft of the Femur. — Section of a right knee-joint and adjacent bones — injected and in spirit, illustrating the above. The patient was an elderly man. His leg was amputated for chronic ostitis. The femur has been condensed, and the surrounding tissues thickened. The two cavities in the femur were occupied in the recent condition by a semi-transparent gelatinous material, which has been shrivelled and rendered opaque by the spirit. The structure of the tibia is practically normal, and may be compared with that of the femur. A caseous gland is seen in the popliteal space. G. C. 3215. Presented by A. G. Miller, F.R.C.S.E. 6. 215. Tubercular Enlargement of the Shaft of the Femur. — The other half of the bones from the previous preparation — macerated. Tubercular Enlargement. 285 The sclerosed condition of the femur is a striking contrast to that of the tibia, which is, if anything, atrophied. The cavities in this half of the femur correspond to those previously noticed in the other half. The periosteal surface of the femur shows irregularity from a deposit of new bone. G. C. 3216. 6. 216. Tubercular Enlarg-ement of the Shaft of the Femur. — Section of the lower end of a right femur — macerated, illustrating the above. " The patient was a woman aged 40. She had long complained of a deep-seated pain in and near the knee-joint, for which she had been blistered, bnt without much beneiit. She died of phthisis pulmonalis." The specimen shows a combination of erosion with new bone formation. The erosion is seen partly in the interior, where the cancellous tissue is destroyed, and partly on the surface, near the lower end, where there are pits and irregular excavations. The new bone formation is seen as an irregular crust on the surface of the lower end of the shaft, resembling the crust due to the irritation of pus-forming organisms. G. C. 858. Presented by Sir George Ballingall. 6. 217. Tubercular Enlargement of the Shaft of the Femur. — Other half of the previous preparation — in spirit, illustrating the above. The spaces in the interior of the bone are occupied by granulation tissue, shrivelled up by the spirit. On the surface similar material has been left in one or two places. G, C. 858 a. Presented by Sir John Ballingall. c. Where the chief changes are in the form of necrosis, combined with absorption or enlargement, or both. 6. 218. Tubercular Disease of the Head of the Tibia.- Upper end of a left tibia — macerated, illustrating the above. 286 Diseases of Bone. There has been advanced tubercular disease of the articular surfaces. The position previously occupied by articular cartilage is opened out and deeply excavated at three places. On the inner articular surface, near the back, there is a piece of necrotic bone in process of separation, and with part of its surface smooth. Round the head of the tibia some new periosteal bone has been thrown out, probably from sepsis. F. P. C. 767. Presented by Professor John Thomson. 6. 219. Tuberculap Disease of the Clavicle.— Right clavicle — macerated, illustrating the above. The bone is very irregular. Portions have been eaten out as if by the burrowing of tubercular granulations, or after the separation of sequestra, and numerous bridges have been left, connecting outstanding spicules with the rest of the bone. The sternal end is the part most affected; the outer end is scarcely changed. Comparatively little new bone has been formed. G. C. 3396. 6. 220. Tubercular Necrosis and Enlarg-ement of the First Metacarpal Bone. — Metacarpal bone of a thumb — macerated, illustrating the above. A shell of new periosteal bone, with numerous cloacal apertures, has formed round the remains of the original shaft. These remains can be seen through the apertures, with the tissue partially opened out, and for the most part absorbed. Described and figured in. Mr Benjamin Bell's work on the Bones, plate i. fig. 7. G. C. 937. Presented by Adam Hunter, F.R.C.S.E. 6. 221. Tubercular Necrosis and Enlargement of the Tubercular Necrosis. 287 First Metacarpal Bone. — Part of the metacarpal bone of a woman — macerated, illustrating the above. It was removed by operation. There is an imperfectly formed new shell, with a hollow interior, from which sequestra have probably been removed. G. C. 995. 6, 222. Tubercular Necrosis and Enlargement of Meta- carpal Bone and First Phalanx.— Part of metacarpal bone and phalanges of a finger — periosteum removed, and in spirit. There is lateral enlargement of the first phalanx, Avith loss of substance near the base, probably from necrosis. The distal end of the metacarpal bone is enlarged. G. C. 566. Presented by Sir George Ballingall. 6. 223. Tubercular (?) Necrosis and Enlarg-ement of Meta- carpal Bones. — Two metacarpal bones — macerated, illus- trating the above. There has been extensive new formation on the surface, with a partial re-absorption of the same. A sequestrum is seen in the interior of the more eroded of the two. Septic mischief has probably complicated this case. W. C. G. 11. 6. 224. Tubercular Disease of Metacarpal Bone.— Plaster cast of right hand, with thumb broken off, illustrating the above. A large swelling has accompanied tubercular disease of the metacarpal bone of the index finger. On the SAvollen part an ulcer is shown, which, no doubt, communicated with the bone. F. P. C. 2887. 6. 225. Tubercular Necrosis and Enlarg-ement of Meta- 288 Diseases of Bone. tarsal Bone. — Metatarsal bone of great toe — macerated, illustrating the above. The original shaft has been attacked by disease, probably tubercular, and lies with its tissue expanded and partially absorbed within a newly-formed periosteal shell. This shell lias several large apertures like irregular cloacae. G. C. 1438. Presented by John Campbell, F.R.C.S.E. 6. 226. Tubercular (?) Disease of Metatarsal Bone.— Left metatarsal bone of great toe — macerated, illustrati-ng the above. "The disease followed a general syphilitic (sic) affection in a young and apparently healthy man ; he had had also a cutaneous disease which was tedious and difficult of cure. The metatarsal bone was removed by the donor, and the toe preserved, but the wound did not heal during the man's stay in the Hospital, which was for many weeks. He had very considerable power in moving the great toe, and in a healthy subject little, or, indeed, no deformity, would have followed the operation." On the inner side of the base there is a deep excavation, the wall of which is formed of rarefied bone. The disease was considered to be syphilitic, but the diagnosis at that time (1828) may not have discriminated between syphilis and tuberculosis. G. C. 1115 Presented by John Campbell, F.R.C.S.E. 6. 227. Tubercular Disease of Metatarsal Bone.— Plaster cast of a front part of a left foot, showing great swelling and ulceration over the inner metatarsal bones. The uniform swelling and the appearance of the ulcers are characteristic of the swellings of the soft parts in the neighbourhood of tubercular bone disease. F. P. C. 2891. 6. 228. Tubercular Disease of Metatarsal Bone.— Head of Tubercular and Septic Disease. 289 the metatarsal bone of a great toe — raacerated, illustrating the above. It is rarefied and partially absorbed, and, as it is said to have been spontaneously separated, it has probably been a sequestrum due to tubercular disease. G. C. 1174. Presented by Professor James Russell. 5. Where the Inflammation has heen chie to the combined action of the tubercle bacillus and of pus-forminrj organisms. 6. 229. Tubercular and Septic Disease of Ulna.— Upper end of a left ulna — macerated, illustrating the above. The articular surface is opened out, and there is periosteal new bone formation on the shaft. Probably tubercular disease of the synovial membrane of the elbow had spread over the articular surface, and had afterwards become septic from the bursting of an abscess. W. C. G. 58. 6. 230. Tubercular and Septic Disease of Femur.— Lower end of the shaft of a right femur, the epiphysis Avanting — macerated, illustrating the above. Amputation was performed, probably for tubercular disease of the joint. The lower end shows the lightening which often occurs near tubercular disease of joints. Some new periosteal bone has been thrown out on the side and back of the shaft. F. P. C. 396. 6. 231. Tubercular and Septic Disease of Femur.— Left femur — macerated, illustrating the above. From a churchyard. There is great incrustation of new bone on the surface, with apparently tubercular disease of the lower articular end. The trochlear surface is rough, and is eaten out as if by 290 Diseases of Bone. tubercular granulations. Probably this has been primarily a case of tubercular disease of the knee-joint, in which an abscess has burst, and turned septic, causing a secondary septic suppuration of the limb, and leading to this periosteal o\itgrowth on the femur. B. C. i. 5. M. 49. 6. 232. Tubercular and Septic Disease of the Tibia.— Left tibia — macerated, illustrating the above. The upper half is very irregular, partly from new bone formation on the surface, especially at the back and on the sides lower down, and partly from erosion and opening out of the bone. The latter change is best seen on the inner tuberosity and at the back of the articular surface. This may have begun as tubercular disease of the head of the tibia which became septic. B. C. I. 5. M. 19. 6. 233. Tubercular and Septic Disease of the Femur and Tibia. — Part of femur, tibia, and fibula for about six inches above and below knee-joint — macerated, illustrating the above. The femur is greatly thickened, and its surface is irregular. The lower articular surfaces are eroded and absorbed in front, and posteriorly are covered by irregular deposits of bone. The cancellated tissue above the articular surface is irregularly hollowed out, and what remains has been rarefied. The shaft of the bone is considerably thickened, and near the upper end shows a periosteal crust, like that due to septic inflammation. Below this, however, the new bone is irregularly absorbed and eaten into, as if by tubercular granulations. The articular surface of the tibia is more complete, although in front it shows considerable depression and excavation as if from tuber' culosis. The shaft of the tibia is greatly thickened and con- densed, and shows irregular new bone formation on the surface. This also has been attacked, but to a less extent than in the Tuhercular and Septic Disease. 291 femur. There are, however, on the inner and posterior surfaces, apertures and depressions, some of which lodge necrotic frag- ments. The fibula shows new periosteal bone formation all over. The outer surface of the patella is also very irregular, from new bone formation. This has probably been a very chronic tubercular affection, with numerous septic sinuses. F. P. C. 398. Presented bij Professor John Thomson. 6. 234. Tubercular and Septic Disease of the Lower End of the Tibia. — Lower end of a left tibia and fibula — macerated, illustrating the above. The leg was amputated for extensive disease of the ankle-joint. The lower half of the tibia shows some new periosteal bone on the surface, with erosion and destruction in the interior. The irregular erosions so often seen in tubercular disease are especially noteworthy about four inches above the ankle. The articular end seems to^have been necrotic, but is also very irregular. The fibula has irregular new bone formation on its surface. This has evidently been a tubercular case, complicated by septic changes. B. C. 2. M. 39. 6. 235. Tubercular and Septic Disease of Radius and Ulna. — Left radius and ulna — macerated, illustrating the above. The crust of new bone on the shafts seems to be the result of sepsis, but the irregular eating away of the crust, especially at the lower end of the ulna, where the original bone is also partly removed, has probably been due to tuberculosis. B. C. I. 5. M. 93. 292 " Diseases of Bone. 6. 236. Healed Tubercular Disease of the Bodies of Verte- brae.— Section of the lower six dorsal vertebrae — macerated, illustrating the above. The bodies of the eighth, ninth, and tenth vertebrae are greatly absorbed, and are infused into one mass of cancellated bone, with only a perceptible trace of the original inter-vertebral discs. The other bodies have been more or less anchylosed on the external surface, and the lamina; and spines of the vertebrae whose bodies are blended are fused together likewise. The specimen shows how completely a tubercular affection of bone' may heal. B. C, i. 3. M. 62, 6. Inflammation of Bone due to Syphilis. A. The SkulL a. Where the chief changes are in the form of rarefaction, i.e. a syphilitic form of caries. («. ) Where the process of rarefaction has been advancing. 6. 237. Syphilitic Disease of the Skull. — Skull-cap apparently of an old man — macerated, illustrating the above. There are patches of opened-out bone ("caries") near the vertex. These patches seem to be due to localised increased vascularity, the opened-out vascular channels in places running together, and forming deficiencies on the surface. The greater part of the vault of the skull is otherwise unchanged, excepting for a slight porosity of the frontal bone. The interior of the skull-cap shows, near the vertex, marks of considerable vas- cularity, both in grooves for larger vessels and in pores for smaller ones. There is some irregularity also near the coronal suture. The sagittal suture is entirely obliterated, and the coronal suture nearly so. F. P. C. 291. Presented by Professor John Thomson. 6. 238. Syphilitic Disease of the Skull.— Skull-cap of an elderly person — macerated, illustrating the above. There are traces of syphilitic disease on the outside, and Syphilitic ' Caries.' 293 extensive changes on the inside. On the outside the parietal bones near the vertex are roughened, chiefly by the enlargement of the vascular pores. On the frontal bone there is also rough- ening, not only by enlargement of vascular pores, but by numerous small grooves on the surface, probably for blood- vessels. On the inside the roughness is chiefly due to new bone formation round small vascular channels, although the pores for entering vessels are enlarged also. The roughness is most marked on the frontal bone, and especially near the middle line. At two places the surface of the inner table is left exposed, and is surrounded by ragged bony spicules of newly-formed bone. Possibly at these places there have been gummatous deposits between the bone and dura mater. B. C. I. 7. M. 8. 6. 239. Syphilitic Disease of the Skull.— Skull-cap of an aged person — macerated, illustrating the above. The bone is roughened over both inner and outer aspects. The outside shows remains of its original smoothness at one or two places only, i.e. near the right frontal eminence, at the temporal ridges, and near the anterior and inferior angle of the right parietal bone. The roughness is due partly to the opening out of vascular channels and partly to shallow depressions of the surface, which are most marked at the back and on the left side of the vertex. At the back of each parietal bone there is a smooth patch entrenched round by a groove, as if necrosis and the process of separation had already begun. Inside, the roughness is very marked on the left side, especially at the site of the coronal suture, but is not quite so extensive on the right side of the middle line. The roughness is mostly due to the development of new bone, but also to the eating out of both the old and the new bone. Erosion and new formation must have gone on side by side. Small apertures are present near the middle of the coronal suture, and at other places. B. C. i. 7. M. 10. 294 Diseases of Bone. 6. 240. Syphilitic Disease of the Skull.— Skull-cap of an elderly person — macerated, illustrating the above. The changes are best seen at and behind the vertex. The bone is unchanged below the temporal ridges, but elsewhere it is more or less porous. At the back and to the left side of the sagittal suture there are numerous irregular apertures, due apparently to enlargement of vascular channels. At places near the vertex areas of bone are mapped out by pores and erosions^ and the surface of the upper part of the occipital bone is similarly roughened. The interior of the skull-cap, especially near places most affected on the outside, shows marks of con- siderable vascularity, but there is practically no bone formation. There are two small bony projections near the front, one on either side of the longitudinal sinus — apparently, by their smoothness, of long standing. The skull-cap is apparently not thickened, but is increased in weight from condensation of the diploe. B. C. i. 7. M. 9. 6. 241. Syphilitic Disease of the Skull.— Portion of left parietal bone — macerated, illustrating the above. There is great roughness on the outside, and sclerosis and thickening of the substance. The roughness on the outside is due to erosion, and the opening out and running together of vascular channels. The interior shows somewhat similar changes, only less marked. On the lower portion of the sawn surface the superficial openings are seen to penetrate well into the bone, and at some places to pass quite through it, while the bone on the section at the upper side is almost uniformly white and dense, like ivory. W. C. G. 41. 6. 242. Syphilitic Disease of the Skull.— Skull of an adult (probably a woman) — macerated, illustrating the above. Changes are present on the frontal, parietal, occipital, superior Syphilitic ' Caries.' 295 maxillary, and left malar bones. The frontal bone is the most affected. Between the frontal eminences there is a large patch where the surface is roughened and in places eaten away. The roughness is due to the opening out of vascular channels. From this patch extensions pass down to the external angular processes, and some tissue is lost at a corresponding part above each orbit. The rest of the vault of the skull shows changes similar to those seen on the frontal bone, only less marked. The bones of the skull are not thickened but the diploii is con- densed. The left malar and superior maxillary bones are roughened on their facial aspect, partly by new periosteal bone, and partly by the opening out of vascular channels. A slight degree of the same change is seen on the right superior maxillary and malar bones. B. C. i. 7. M. 22. 6. 243. Syphilitic Disease of the Skull.— Skull and lower jaw of a negro — macerated, illustrating the above. At the right frontal eminence and below the left one there is considerable loss of the surface from erosion, and possibly from superficial necrosis. On the left side the skull is also perforated. Eound these places there are the usual pores due to increased vascularity, which have been opened out into irregular pits here and there. A somewhat similar condition is seen on the lower jaw, below and behind each mental foramen. Some roughness is seen on the malar and superior maxillary bones. In the interior of the skull there are marks of increased vascularity at various places, but especially on the frontal bone. The skull, as a whole, seems thick, and the sutures are distinct. B. C. I. 7. M. 25. 6, 244. Syphilitic Disease of the Skull.— Skull of an adult, apparently a woman — macerated, illustrating the above. All over the vault there are patches of loss of surface or 29& Disease's of Boner bone ulceration, as it has been called, and the changed and unchanged parts are in close proximity. A certain amount of symmetry in the diseased patches is seen on the frontal bone, and on the front of the parietal ; but the most advanced patch, Avhich is on the right of the vertex, has no corresponding patch on the left side. At some places the bone is quite smooth, and at others the vascular channels are opened out, sometimes into fine pores, sometimes into pits and erosions, as noticed in previous specimens. On the patch to the right of the vertex these excavations have nearly encircled a piece of bone, which is itself porous. These excavations, or bone ulcers, seem to have been advancing on the right side, while others on the left have been healing over. The interior of the skull over the vault is roughened by enlargement of vascular channels. The diploe is almost entirely filled up by sclerosed bone, and the skull is somewhat increased in weight. The sutures are unusually distinct. B. C. i. 7. M. 23. 6. 245. Syphilitic (?) Disease of the Skull.— Portion of a skull — macerated, illustrating the above. There is a loss of substance on the outer surface, which has penetrated into the interior. The section shows the bone to be thickened and sclerosed, F. P. C. 2962. (h.) Where the 'process of rarefaction has been healing. 6. 246. Syphilitic Disease of the Skull.— Skull-cap— macerated, illustrating the above. The upper surface, especially near the vertex, is roughened, but the irregularities are rounded off as if healing. On the inner aspect, especially at the upper portion of the longitudinal sinus, there are marks of increased vascularity. G, C. 988. Syphilitic ' Caries: 297 6, 247. Syphilitic Disease of the Skull.— Skull-cap, with ununited frontal suture — macerated, illustrating the above. Between the temporal ridges the parietal bones have been roughened on the surface, partly by vascular pores, and partly by irregular excavations, which, as in the previous specimen, have been smoothed over. The interior of the bone shows an increased number of channels for the branches of the middle meningeal artery. The sutures are unusually distinct. B. C. I. 7. M. 6. 6, 248, Syphilitic Disease of the Skull.— Bkull— macerated, illustrating the above. There are marks of previous disease on the frontal, malar, superior maxillary, and sphenoid bones. The frontal bone shows irregular rounded depressions and marks of increased vascularity on its anterior and lateral parts. Both malar bones, but especially the right, are roughened by enlargement of the pores for blood-vessels. A similar condition is seen below the nasal aperture and on the roof of the hard palate. The under surface of the body of the sphenoid behind the nasal septum is absorbed, and ^has an aperture into the sphenoidal sinuses. The interior of the skull shows numerous markings due to increased vascularity, not only on the frontal but also on the parietal bone, on which there are very few marks on the outside. B. C. I. 7. M. 20. 6. 249. Syphilitic Disease of the Skull.— Skull-cap of an elderly person — macerated, illustrating the above. There are marks of former disease on the frontal and left parietal bones. Several irregular excavations are seen near the frontal eminences, especially on the left side, and there is another above the left parietal eminence. The margins of these are smoothed over as if the disease had subsided. The interior of 298 Diseases of Bone. the skull shows marks of increased vascularit}', especially in the frontal bone, where there has also been some tliickening. The frontal bone where sawn is considerably thickened and condensed. B. C. i. 7. M. 7. 6. 250. Syphilitic Disease of the Skull. — Skull of an adult man — macerated, illustrating the above. The whole of the outside of the skull is roughened and irregular. (3n the right side the changes seem to have been o^f long standing and are partially healed. The lower part of the parietal bone has irregular tubercles smoothed over, and the surrounding bone has few vascular channels. On the corre- ponding part on the left side and in front there are alsO' similar tubercles, but their margins are sharper and the bone round is more porous. The Avhole of the top of the skull is porous, and at places the apertures are opened out into irifegular erosions. There is, in fact, scarcely any part of the external surface of the cranial bones which is not changed by an early or receding stage of the opening-out process. Most of the facial bones show similar changes. On the left eminentia articularis- there is a smooth undermined and partially separated scale of bone, as if a layer of the articular surface had been necrosed. On the inside of the skull, except on the anterior and middle fossae,, the surface is roughened by the development of new bone and by the enlargement of vascular channels. B. C. i. 7. M. 21. h. "Where the chief changes are in the form of enlargement. 6. 251. Syphilitic Disease of the Skull.— Portion oi a left frontal bone — macerated, illustrating the above. The outer surface shows several eminences, the surfaces of which are porous. The section shows the bone to be thickened, the texture being at some places rarefied and at others sclerosed in irregular patches. W. C, G, 39. Syphilitic Necrosis. 299 c. "Where the chief changes are in the form of necrosis. 6. 252. Syphilitic ("Mercurial") Disease of the Skull.— Portion of the left half of the skull-cap — macerated, illustrat- ing the above. An irregular smooth patch in front of the parietal eminence is almost entirely surrounded by irregular depressions, which seem to be enlargements from dilated vascular channels. Similar but less advanced stages of the' same process are seen behind this large patch. On the inside a certain amount of increased vascularity is traceable. The diploii is partially filled up, and the bone as a whole is increased in Aveight. The cranial sutures are nearly obliterated. F. P. C. 317. Presented by Professor John Thomson. 6. 253. Syphilitic Disease of the Skull, advancing- to Necrosis. — Skull-cap of an old person — macerated, illustrating the above. There are patches of roughened surface on the frontal and parietal bones, but most marked on the right side, where the opened-out vascular channels have been in many places enlarged into irregular pits. Near the right parietal eminence irregular trenches are marked out round portions of the bone. At one place below, the trench communicates with the interior. On the inside of the skull the bone shows enlarged vascular channels all over, but most marked opposite the patches affected on the outside. Xear the inner aspect of the right parietal eminence the bone is almost entirely eaten through over an area smaller than, but similar in shape to, that on the outside. B. C. I. 7. M. 12. 6. 254. Syphilitic Disease of the Skull, with Necrosis.— Oblique section through ^the upper part of the vault of a skull — macerated, illustrating the above. The bone has been trephined. 300 Diseases of Bone. The reason for the trephine opening does not appear. The specimen shows an irregular piece of necrotic bone partially entrenched round, and with vascular channels in process of opening out extending bej'^ond. The inside shows some enlargement of vascular pores. The diploii is condensed. The margin of the trephined aperture shows that the above patch of bone was being undermined from below as well as from the sides. AY. C. G. 47. 6. 255. Syphilitic Disease of the Skull, with Necrosis.— Skull-cap of an old person — macerated, illustrating the above. The outer surface at the top shows roughness, chiefly from the increased size of the pores for blood-vessels. Above the right frontal eminence is a depression with a raised margin. The edges are rounded off, as if the part had been healing. Below the left parietal eminence an area of one and a half inches by three-quarters of an inch has been in process of separation, and is entrenched round by a distinct groove. The surface of this piece is porous and rough, as in other cases of sj'-philitic necrosis. Below the right temporal ridge the parietal bone has been trephined for reasons unknown. On the inside, below the mark near the right frontal eminence, there is a distinct thickening of bone, with marks of increased vascularity. Beneath both parietal eminences, especially the left, there are marks of increased vascularity. The diploe is condensed, and the bone is much increased in weight. The posterior part of the sagittal suture is entirely obliterated. B. C. I. 7. M. 11. 6. 256. Syphilitic Disease of the Skull, with Necrosis.— Portion of a parietal bone — macerated, illustrating the above. A small necrotic piece, which is eroded on the surface, is partly undermined as well as grooved round. The interior of the bone shows marks of increased vascularity, and the diploe is, Syphilitic Necrosis. 301 for the most part, replaced by dense bone. This was formerly described as "mercurial caries, with commencing exfoliation of the outer portion of the skull." F. P. C. 318. Presented by Professor JoHX Thomson. 6. 257. Syphilitic Disease of the Skull, with Necrosis.— Portion of the vault of a skull — macerated, illustrating the above. A large necrosed fragment in process of separation. The outside shows the disease less advanced on the right of the middle line. The roughness is in various stages from opened- out vascular channels to irregular erosions, and one of these is at one place nearly healed over. On the left side, a large fragment, whose surface is for the most part destroyed, has been partially separated, and a groove has been formed round it. From the inside it can be seen that the necrosis, except over a limited area, had not been complete all through, the deeper layers of the bone having furnished granulations for the process of separation. The general inner surface shows marks of increased vascularity. The bone, except at the necrosed part, has been thickened and condensed. W, C. G. 42. 6. 258. Syphilitic (?) Disease of the Skull, with Necrosis.— Anterior and left portion of a calvarium — macerated, illustrating the above. The outer surface shows some roughness, chiefly in the form of superficial grooves for blood-vessels. Behind the coronal suture, near the middle line, there is considerable loss of substance, and a small trephine hole penetrates the inner table. A superficial layer of bone seems to have separated from the outer surface here, leaving an irregular deficiency with a. ragged base. On the inside the bone is greatly thickened 302 Diseases of Bone. and roughened by marks of numerous blood-vessels. Corre- sponding to the deficiency on the outside, there is a smooth necrosed portion of the inner table perforated by the trephine, and surrounded by a raised margin of thickened bone. It is triangular in shape, and leading from the apex of the triangle, and parallel with the coronal suture, is a deep groove upon a raised ridge of bone. In the absence of any clinical history the explanation of those appearances, which differ from those of most of the ordinary specimens of syphilitic disease of the cranium, is difficult. G. C. 369. 6. 259. Syphilitic Disease of the Skull, leading* to Necrosis. — Skull-cap, probably of a woman — macerated, illustrating the above. From the vertex forwards the changes are more and more marked. Except on the necrosed part in front, and on the margins round it, the irregularities of the roughened surface have all been smoothed over. Some smoothing over is per- ceptible, even on the necrosed part itself, from which it would appear that the necrosis had resulted from a recrudence of the disease after the subsidence of a former attack. About the level of the frontal eminences a mass of very irregular, apparently necrosed bone is in process of separation. It measures two and a half inches by one and three-quarter inches, and lies obliquely across the forehead. The groove round it penetrates the thickness of the skull completely at the upper and left parts, and in places below, but on the right side the groove does not go deeper than the diploe. For the most part the edges of the grooves overhang the dead part. On the inside there is likewise a groove round the dead part, and this aspect of it is as rough and irregular as the outer one. There are marks of increased vascularity all over the interior of the vault, but especially in front. The section of the bone is greatly thickened in front of the necrosed area, but elsewhere it is thin, B. C. i. 7. M. 15. Syphilitic Necrosis. 303 6. 260. Syphilitic Disease of the Skull, ending in Necrosis. — Portion of skull, tapper and back parts wanting — macerated, illustrating the above. There has been extensive destruction of the frontal and nasal bones. On the outer surface the parts not necrosed are roughened from increased vascularity. Almost the whole of the frontal region is occupied by a roughened seques- trum, which seems to have been detached and only held in place during life by the soft parts, for it is now glued into position. Its surface is roughened by apparently recent and old-standing changes, similar to those already described, and part of the surface seems to have been detached as a superficial necrosis. All round it there is a groove, which, however, has not penetrated through the inner table, and the margins of which for the most part overhang. The frontal sinuses are exposed, but their mesial septum remains. The bones forming the bridge and sides of the nose are wanting, and the ethmoidal and maxillary sinuses are freely exposed. The vomer is deficient, and there is a large gap near the front of the hard palate. The interior of the roof of the skull is roughened by marks of dilated blood-vessels, but to a less extent than might have been expected from the changes on the outside. Only at one spot — near the middle line in front — has the process of necrosis penetrated into the interior. On the base of the skull the bony ridges are sharp and strongly marked, both inside and outside. The section of the skull in the parietal and occipital regions is extremely thick, and the diploe is everywhere replaced by compact bone. F, P, C. 475. Presented by Professor JoHX Thomson. 6. 261. Syphilitic Disease of the Skull, ending" in Necrosis. — Scalp of a man — macerated, illustrating the above. ' ' About two years before I saw this man he fell and struck his head against a log of wood. Some time after this he was grievously attacked with pains in his forehead, and about the shoulders and clavicles. Corona 304 . Diseases of Bone. veneris formed upon his forehead, and, the integuments ulcerating, dis* closed a dead and black portion of the bone. This portion, after some mouths, came away. The caries extended, and a second portion was in progress of being thrown off. The dura mater burst, and fungus cerebri forming, the man sank into low delirium, with convulsions of the face, and expired." The upper part of the skull shows at various places roughness and irregularity, which seem to have healed over. Occupying the greater part of the frontal bone are two sequestra, with their surrounding grooves. The larger is on the right side, and crosses the middle line below. It shows signs of old-standing disease on its surface, and has been completely detached. The smaller one on the left side has similar marks on its surface, and is surrounded by a groove, which below has penetrated through the inner table. On the inside, near the vertex, there are marks of old-standing vascularity, but near the necrosed pieces the roughness from increased vascularity is greater, and has apparently been recent. The process of necrosis has involved the inner table in both places, but the area of necrosis is less on the inner than on the outer surface. B. C. i. 7. M. 17. 6. 262. Syphilitic Disease of the Skull and Facial Bones, with Necrosis of the Palate. — Skull and lower jaw of a man who died from syphilis — macerated, illustrating the above. " In the month of May last (1824) I was requested by a gentleman in town to visit the individual to whom this skull belonged, aud found him lying on a couch, extremely reduced and emaciated ; the face and upper part of the scalp covered with numerous blotches and incrustations, one of which was particularly prominent, and projected like a horn over the centre of the frontal bone. ' ' Various superficial ulcerations and blotches were also conspicuous on his body and limbs, but these he did not seem inclined to show me to their full extent, as he appeared to have lost all hopes of cure, and con- sidered me, I believe, as only visiting him from motives of curiosity. The same idea rendered him very little communicative as to the history of his complaint, and he seemed quite unable to give any distinct or connected account of their progress. All I could learn from him was that the disease had commenced by an ulceration on the penis, and destroyed Syphilitic Necrosis. 30'5 part of the glands ; that he had also been affected with buboes in the groins, and subsequently with ulceration of the throat, cutaneous eruptions, and exfoliation of spiculse of bone from the nostrils ; that he had laboured under the disease for three or four years, had been under the care of various practitioners, and had used much mercury, besides other remedies. " He was now, I found, using the decoction of sarsaparilla under the direction of Dr Kennedy, which I desired him to continue ; and after consulting with Dr Kennedy we agreed to prescribe the Plumnier's Pills, of which he was directed to take three daily along with the decoction. Under this course a rapid amendment took place ; the incrustations dropped off from his skin ; he recovered his looks and flesh, and in short complained of nothing but an offensive discharge from the nostrils. His spirits got up, and he seemed to entertain sanguine hopes of recovery. In this state he came over from the Old Town to my house late one evening in the month of July, during the prevalence of a cold easterly wind ; he complained of having caught cold, was exceedingly hoarse, and upon inspection the palate and fauces were found considerably inflamed. On enquiry I ascertained that of late he had been repeatedly out at night, and had been living altogether in a very irregular and dissipated manner. I ordered him home instantly, desired him to confine himself entirely to the house, to lay aside the use of the Plummer's Pills, to take a dose of salts, and to go into the warm bath ; which directions, with the exception of the confinement, I have reason to believe he complied with. "Soon after this an ulcer broke out in the palate immediately behiml the incisors — the velum palate and tonsils also became ulcerated — the- offensive discharge from the nostrils increased — pieces of the inferior spongy bone exfoliated — the teeth dropped from their sockets — and though mercury in every form had for some time been laid aside, a copious salivation now commenced, owing to the irritation from the diseased state of his mouth affecting the salivary ducts and glands. He was unable to take almost anything in the shape either of food or medi- cine. Of the latter nothing was recommended to him but bark, laudanum, laxations, and an alum gargle. He continued to linger for several Aveeks, and expired about the beginning of November, greatly emaciated, aiid exhausted by hectic fever. " On examining the exterior surface of the cranium, a circular portion of the right parietal bone, about the size of a shilling, may be observed flattened and somewhat rough ; from this an exfoliation had taken place previous to the patient's coming under my care. On the interior surface of the bone opposite to this spot the impressions of numerous small vessels are to be seen deeply indented into the bone, and giving it a rough scabrous feel. " On the internal aspect of the frontal bone two circular U 306 Diseases of Bone. portions are to be seen marked by the impressions of numerous small vessels similar to what is observed on the parietal bone, "Large portions of the superior maxillary bones, including the alveolar process of the front teeth, are in the process of exfoliation. " On examining the base of the skull, the condyloid and cuneiform processes of the occipital bone and the posterior clinoid processes of the sphenoidal bone may be observed partially diseased" (Edin. Med. Chir. Trans, vol. i.). On the interior, besides the points above noted, new bone has been thrown out round the numerous blood-vessels alluded to. G. C. 723. Presented hy Sir George Ballingall. 6.263. Syphilitic Disease of the Skull, with Destruction of the Nose. — Skull — macerated, illustrating the above. " During life the patient exhibited a horrid spectacle. I could see into the throat, so as to observe the motion of the velum palate, while he was speaking. Some time after the disease was stopped in its progress, the cranium became affected. It did not, strictly speaking, exfoliate, but the whole substance came away. The pulsation of the brain forcing the dura mater against the edge of the bone, it was desti'oyed by ulcera- tion, and fungus cerebri followed, when the man died." There is an aperture just behind the centre of the coronal suture, extending backwards for two and a half inches. It is widest about half an inch from the front, where it measures two inches across, and becomes narrower towards the back. The edges are sharp and jagged, and the margin is bevelled from the outside. The bevelled portion on the front and left side is mostly smoothed over, as if the process had ceased there, but on the right side it is irregular, as if still in progress. The greater part of the frontal bone shows numerous vascular markings, producing a mosaic-like pattern, the result apparently of horizontally running blood-vessels. At one or two places there are patches of opened-out vascular pores. Below the right frontal eminence is a patch of necrotic bone, irregularly circular in outline, and measuring one and a half Syphilitic Necrosis. 807 inches across. This piece is surrounded by a distinct trench, which below has penetrated through the skull. The sides and back of the calvarium are comparatively unchanged, but the bone is increased in thickness and the diploe is partially filled \\Y>. The vomer, nasal, lachrymal, inferior turbinated, and greater part of the ethmoid and nasal portion of superior maxillary bones have entirely disappeared. The ethmoidal sinuses and the antrum of Highmore on each side are completely exposed from the nose. The back of the palate is gone, and only a trace of the nasal septum is seen at the roof. Marks of increased vascularity are seen on the malar bones below each orbit. The back of the skull shows at various places patches of roughness owing to increased vascularity. B. C. I. 7. M. 18. 6. 264. Syphilitic Disease of the Skull after Separation of a Sequestrum. — Portion of right frontal and parietal bones — macerated, illustrating the above. In front there is an aperture with rounded margins, as if necrosis had separated and the part healed. Behind that, and separated from it by a bridge of bone, is another aperture, more irregular and with sharper margins, as if a sequestrum had only recently separated from it. On the inside there are marks of increased vascularity, old-standing in front and recent behind. K^ear the apertures the bone is irregular and eroded in both aspects, but this surrounding irregularity does not correspond on the two aspects. "\Y. C. G. 46. 6. 265. Syphilitic Disease of the Skull after Separation of a Sequestrum. — Portion of the left half of a calvarium — macerated, illustrating the above. There is an irregular aperture in the parietal bone, about three inches in diameter each way. The margins of this apertiire are sharp, and a large sequestrum must have only recently separated from it. On the outer surface of the 308 Diseases of Bone. parietal bone some ncAV periosteal bone has formed below and in front of the aperture. The interior of the bone shows- deepened grooves for blood-vessels, and, behind the coronal suture, there is a very deep one like that noted in a similar situation upon No. 6. 245. G. C. 368, d. Sequestra, due to syphilis, after separation, 6. 266. Sequestra after Syphilitic Disease of the SkulL — Four sequestra from the skull, probably from different cases. The largest, which measures four by three and a half inches at its greatest diameters, shows marks of old-standing and recent irregularity on both sides, but mostly on the inner side. Apparently the inner palate has only been involved in necrosis here and there, for its surface is very irregular. The other pieces, although smaller in size, seem to have more completely involved the whole thickness of the skull. In one, the outer table is comparatively unchanged, while the irregularity is very great on the inner side. In the other two the irregularity is most marked on the outer side, although distinct on the inner side also. G. C. 1169, Presented hy Professor James Russell, 6. 267. Sequestrum after Syphilitic Disease of the SkulL — Sequestrum, involving whole thickness of skull. Described previously as " mercurial exfoliation." There is great irregularity on the outer surface and marks of increased vascularity on the inner surface. F. P. C. 480. Presented hy Professor John Thomson. 6. 268. Sequestrum after Syphilitic Disease of the Skull. — Sequestrum, which has involved both tables of a thickened skull. Syphilitic Necrosis. 309 From the skull of a young gentleman who died of affection of the spine. The piece of bone is markedly irregular on both surfaces, and presents the usual characteristics of a syphilitic sequestrum, G. C. 1620. Presented by Adam Hunter, F.R.C.S.E. 6. 269. Sequestrum after Syphilitic Disease of the Skull. — Sequestrum (sawn through at one spot), formerly described as " mercurial exfoliation " of both sides of the skiill. The necrosis has involved the whole thickness of the skull, and both surfaces, but especially the inner, show the roughness and irregularity characteristic of a syphilitic sequestrum. F. P. C. 481. 6. 270. Sequestrum after Syphilitic Disease of the Skull. — Sequestrum involving the whole thickness of the skull. Both surfaces show irregularity characteristic of a syphilitic sequestrum. G. C. 1167. e. Specimens illustrating healing after separation of syphilitic sequestra. 6. 271. Syphilitic Disease of the Skull after Separation of Sequestrum. — Frontal portion of a calvarium, with scalp — in spirit, illustrating the above. Just below the roots of the hair, to the right of the middle line, there is a small healed ulcer of the skin, with a small frag- ment of necrosed bone on its base. The margins of the ulcer are smooth, and, though somewhat overhanging, seem completely covered with epithelium. On the floor below the necrosed fragment the bone is covered by a thin layer of fibrous-looking material, possibly epithelium. The interior of the bone has dura mater clinging to it in many places, and where bare shows marks of increased vascularity. The skull itself is thickened and condensed. B. C. i. 7. M. 1. 310 Diseases of Bone. 6. 272. Syphilitic Disease of the Skull after Separation of Sequestrum. — Skull-cap of an old person, probably a woman — macerated, illustrating the above. On the frontal bone, to the right of the middle line, and extending downwards from about one and a half inches below the coronal suture, there is a rough irregular depression. It shows a perforation above, and ends in a deep branching groove below. The margins are bevelled off, and in some places the irregularities are rounded as if there the disease had been healing, while at others they are sharp as if it had been extending. The interior of the bone shows marks of increased vascularity, especially on the frontal bone, which is thickened on the right side, and shows irregular depressions on the left. The bone, as a whole, is thin, but the diploe is condensed. G. C. 367. 6. 273. Syphilitic Disease of the Skull— Healing" after Extensive Destruction. — Skull of an adult — macerated, illustrating the above. The disease has been most advanced on the frontal bone and on those of the face, round the nose and mouth. On the ovitside there is considerable roughness and porosity near the external occipital protuberance. The diploe, where exposed, seems for the most part normal. The whole of the lower part of the frontal bone is also roughened and irregular. Above, the irregularities are shallow, and the surface is smoothed over, but below they are deeper and the bone surface is porous. At one spot the frontal sinus has been opened into. The margins of the anterior nares have been attacked, and the bone is porous. The alveolar border shows similar changes, and many of the teeth must have fallen out shortly before death. The hard palate is roughened, and on the left side is perforated by a small aperture. The interior of the skull shoAvs marks of increased vascularity, especially in the frontal region, but this is less marked than might have been expected from the condition of the outside. B. C. i. 7. M. 24. Healing after Syphilitic Necrosis, 311 6. 274. Syphilitic Disease of the Skull— healed after Loss of Substance. — Portion of the right frontal and parietal bones of an old person — macerated, illustrating the above. On the outer surface there are numerous smooth excava- tions and tubercles, and at one place a small perforation, with rounded margins. On the inside the changes are very slight, merely some irregularity near the perforation. The coronal suture is obliterated except at a small place near its lower end. This seems to be a case where the disease had completely subsided. Formerly described as " a caries of the left parietal bone." G. C. 370. 6. 275. Syphilitic Disease of the Skull— healed after Loss of Substance — Skull-cap of an adult, with permanent frontal suture — macerated, illustrating the above. On the right parietal bone, near the vertex, is a circular depression, one and a half inches in diameter, with a sinuous rounded margin and irregular base, which has been smoothed over. This is as if a superficial sequestrum had been separated some time before, and the part had healed over. In front of the left parietal eminence is a shallow depression, with a base, which is at one place smooth and at others rough, as if the disease have been in process of cure. The interior of the skull shows some marks of increased vascularity. W. C. G. 18. 6. 276. Syphilitic Disease of the Skull— healed after Loss of Substance. — Portion of the front of a calvarium, with permanent frontal suture — macerated, illustrating the above. There is a depression, one and a half inches long by one incli broad, between the frontal eminences. Its margins are bevelled off and smoothed over, and its base, Avhich is also smoothed 312 Diseases of Bone. over, is perforated by a narrow aperture communicating with the groove for the longitudinal sinus. The inner surface has marks of increased vascularity. The section of the bones shows thickening, but the diploe still present. B. C. i. 7, M. 26. 6. 277. Syphilitic Disease of the Skull— healed after Loss of Substance. — Skull-cap — macerated, illustrating the above. The anterior part of the frontal bone shows two large irregular depressions of the surface ; one is on the right side, and is deeper, larger, and more irregular than the other, which extends from the middle line to the left frontal eminence. Except where the two depressions are contiguous, their margins are slightly but distinctly raised. On the left side this raised margin shows grooves and pores for numerous blood- vessels, as if the process had been in progress, while on the right side the surface of the raised part has been smoothed over, A small hole in the base of the right depression com- municates with the interior. The cerebral surface shows marks of increased vascularity on the parietal and frontal bones. The section of the frontal bone is increased in thickness. At other places, although the bone is not thickened, the diploe is condensed. F. P. C. 476. Presented by Professor RussEll. 6, 278. Syphilitic Disease of the Skull— healed after Separ- ation of a larg-e Sequestrum. — Anterior portion of the right half of a calvarium and roof of orbit — macerated, illustrating the above. During life a fungus cerebri projected through the aperture left by the separation of a large sequestrum. The aperture is irregularly circular, and measures two inches by three and a half inches in diameter. Its margins are rounded off', as if the disease had subsided and the parts had been healing. B. C. i. 7. M. 16. Syphilitic Destruction of Face. 313 6. 279. Syphilitic Disease of the Skull— healed after Loss of Bone about the Nose and Left Orbit.— Anterior half of a skull — macerated, illustrating the above. The bridge of the nose, nasal septum, and margins of the nasal cavity have been lost, and a single rounded aperture represents the anterior nares. There is a small aperture in the hard palate. The ethmoidal and sphenoidal sinuses are no longer traceable. Their position is now occupied by roughened bone. The antrum of Highmore on each side is nearly filled in by similar roughened bone, but an opening into the frontal sinuses is still present. The outer wall of the left orbit is for the most part wanting, and the disease here seems to have been in progress at the patient's death, although at other places it must have subsided. The interior of the skull is irregular, apparently from development of bone round the blood-vessels. The section of the cranial vault shows an increased thickness and partial filling up of the diploe. B. C. i. 7. M. 19. 6. 280. Syphilitic Disease of the Nose and Mouth.— Cast in glue and glycerine of the face of a woman, illustrating the above. The bridge of the nose has been destroyed, and its fleshy part is represented by an irregular scar. The upper lip is greatly scarred. This cast represents the appearance of patients after severe destruction of the nose. G. C. 3557. 6. 281. Syphilitic Disease of the Bones of the Face, with very g'reat Destruction. — Plaster cast of the front of the head and neck of a man, illustrating the above. Described by Sir Charles Bell as "A cast exhibiting the effects of the disease called noli me tangcre, or rather that kind of it which is called lupus, in -which the face is gnawed or eaten away. The man from whom this was taken was long a patient in the Hospital. When he swallowed, the action of the muscles of the fauces could be observed." !14 Diseases of Bone. The face has been destroyed, and the orbits, mouth, and nose are thrown into one common gap. From the appearance of the face and the indefiniteness of former nomenclature, it seems right to classify this as syphilis. B. C. I. 6. M. 39. B. The Skeleton. f. Where the chief changes are in the form of enlargement. 6. 282. Syphilitic Disease of Skeleton.— Male skeleton, want- ing the skull, illustrating the above. The vertebrge show an increased vascularity on the bodies and lamiucB. The ribs are not appreciably altered. The clavicles show enlarged pores for blood-vessels, but nothing that is characteristic. On the scapulae the posterior part of the spines, especially the left, is somewhat thick and irregular, but otherwise there is no appreciable change. The right humerus is considerably thickened at its lower end by periosteal new bone formation, most marked in front. There the surface, besides being irregular, is in places eroded as if the new material were being absorbed again. The periosteal crust diminishes from below upwards, and does not quite reach the deltoid attachment on the outer side, although it can be traced further up on the back. The rest of the bone shows only an enlargement of vascular pores. The left humerus has only a very slight periosteal crust, about the middle of the posterior surface. Elsewhere the surface of the bone is rough from enlargement of the vascular pores. The right ulna shows only some periosteal crusts on the outer side of the upper end, and enlargement of vascular pores at other places, but the left ulna shows a very distinct thickening all round the shaft, about the middle. The changes at the upper end correspond to those on the right side. The radii show an increased size of vascular apertures and some periosteal new bone formation on the upper part of the outer surface. On the right side, in addition, there Syphilitic Affections of the Skeleton. 315 is a slight deposit of periosteal bone, just above the front of the lower articular surfaces. The bones of the hand show no definite change. The pelvis shows no characteristic change. On both sides the vascular channels seem unusually well marked, and on the right side, the outer surface of the ilium is slightly roughened by periosteal formation. The right femur is thickened from the lower end up to about the middle, but more behind than in front. The surface of the thickening has all the appearance of new periosteal formation, and is more irregular on the back than in front. One vascular channel on the back is enlarged into a distinct aperture. The shaft of the left femur is thickened about the middle, mostly on the inner side, but also' slightly all round. A periosteal crust can be traced downwards to the knee-joint, especially on the inner side. On both tibiae the vascular pores are enlarged, and some new bone has been formed on the shin surface and at the attachment of the tibialis anticus muscle. Both fibulae show slight periosteal rough- ness at the muscular attachments, and an enlargement of vascular pores. The bones of the foot show no appreciable change. G. C. 3391. 6. 283. Syphilitic Disease of the Clavicle.— A left clavicle- macerated, illustrating the above. The greater part of the bone has been afi'ected. About the middle the anterior and upper parts have been attacked,, and an excavation has been formed, in the base of which are fragments of necrotic-looking bone partially separated. This excavation is surrounded by new periosteal bone, which passes round to the under surface, and fades off at either side. The outer end of the bone is irregular and partially absorbed, and near it new periosteal bone has been formed. G. C. 993. 6. 284. Syphilitic Disease of the Sternum.— Sternum- macerated, illustrating the above. 316 Diseases of Bone, The bone is increased in weight, and its surfaces are encrusted with new periosteal bone, probably from syphilis. B. C. I. 5. M. 12. 6. 285. Syphilitic Enlargfement of the Humerus.— Section of a right humerus — injected with vermilion, partially cleaned and in spirit. The specimen is from a patient who was supposed to have had syphilis. There is thickening of the shaft at the back of the lower end, and patches of vascularity and crusts of new periosteal bone are scattered up and down. B. C. i. 5. M. 1. 6. 286. Syphilitic Enlarg-ement of the Humerus.— Right humerus — macerated, illustrating the above. The bone is increased in weight, and is thickened on its inner and posterior surfaces, especially at the junction of the lower and middle thirds, where a large node has been formed. The prominent part of the node is formed of irregular pro- jections, which get smaller towards the margin. The head and neck show little change. B. C. i. 5. M. 89. 6. 287. Syphilitic Enlarg-ement of the Humerus.— Upper portion of left humerus from the same patient as the last — macerated, illustrating the above. The disease on this side is more advanced. A node, some- what similar to the last, but at a lower level, has been present. This node, however, has contained a necrosed piece of bone, still adherent but in process of separation, and having cloacae leading to it. A section has been made through one of the cloacse to show the structure. The whole of the upper part of the shaft is encrusted with new periosteal bone, except here and there where the original surface is seen through it. B. C. I. 5. M. 90. Syphilitic Enlargement. 317 6. 288. Syphilitic Enlarg-ement of the Humerus.— Right humerus — macerated, illustrating the above. The bone is increased in weight and thickened at its lower end. The surface of the thickened part is extremely rough from projecting processes of periosteal bone. The parts most affected correspond to the places of attachment of the triceps and brachialis anticus muscles. B. C. i. 5. M. 88. 6. 289. Syphilitic Enlargement of the Humerus.— Eight humerus — macerated, illustrating the above. The lower end is thickened, especially upon the posterior and outer surfaces. In several places an erosion of the new bone penetrates also into the old, as if an ulcer or sinus in the soft parts had extended downwards into the bone. B. C. I. 5. M. 91. 6. 290. Syphilitic Enlargement of the Radius and Ulna.— Right radius and ulna, from the same patient as No. 6. 285 — injected with vermilion, surface cleaned, and in spirit, illustrat- ing the above. Considerable irregular periosteal growth is seen on the radius, especially on the back near the two ends. On the upper end of the ulna, especially at the outer and back parts, there are patches of vascularity and crusts of new periosteal bone. B. C. i. 5. M. 1. 6. 291. Syphilitic Enlargement of the Ulna.— Right ulna- macerated, illustrating the above. The upper end is greatly enlarged and irregular. Its posterior surface is also eroded and rarified, as if it had formed the base of an ulcer. The lower end of the bone and the articular surfaces are unchanged. B. C. i. 5. M. 92. 318 Diseases of Bone. 6. 292. Syphilitic Enlarg-ement of the Ulna.— Shaft and upper end of a left ulna — macerated, illustrating the above. The shaft is irregularly thickened from below upwards by periosteal formation, and its surface is nodular and ["porous. The disease has extended between the two sigmoid cavities of the upper articular surface. B. C. i. 5. M. 95. 6. 293. Syphilitic Enlargrement of Radius and Ulna.— Right radius and ulna (head wanting) — illustrating the above. The Haddington Parish Church, or " The Lamp of Lothian," as it was formerly called, was originally built in the eleventh century. In 1423 a new floor was laid down, and other alterations were made, and it is recorded that there were fifteen altars in the church placed near the bases of the eight pillars, of which four run along each side. In 1811 a wooden floor was put in, galleries erected, and the church reseated. In 1891 the church was renovated, and among other alterations a concrete floor was laid down. In preparing the ground for the cement, about eighteen inches of a loose sandy soil was taken away from below the former wooden floor, and it Avas in this soil that the bones were found. There was no trace of coffins of any kind ; most of the bones lay near the pillars, and therefore near where the altars formerly stood. Although the interior of the church is known to have been used occasionally for burial purposes up to the end of the eighteenth century, it seems probable that the bones found round the pillars had been interred there before 1423, and therefore are not unlikely to have been those of monks. These bones formed part of the only complete skeleton found. The shaft of the ulna, as in the two former specimens, is gradually thickened from the lower end upwards, and the surface, although uneven, is comparatively smooth, as if the disease had been long quiescent. The shaft of the radius is thickened, chiefly about the middle. Its surface resembles that of the ulna. The lower Sypliiliiic Enlargement. 319 articular surfaces are altered in shape as if from arthritis deformans. G. C 3346. Presented by W, R. Martine, M.B., CM., Haddington. 6, 294. Syphilitic Enlargement of the Radius.— Right radius —macerated, illustrating the above. There is an irregular thickening of the lower end of the bone, beginning a little above the articular surface, and extend- ing up to the middle. The thickened part is very irregular, partly from eating out of its surface, and partly from the forma tion of new bone. It has the appearance of a node, which had become the seat of destructive changes. W. C. G. 31. 6. 295. Congfenital Syphilitic Enlarg'ement of the Radius. — Plaster cast of the right forearm of a boy, showing a swelling over the upper part of the radius. The boy had " Hutchinson's teeth," and ulcerations of the palate and nose. There was a clear history of syphilis in his parents. G. C. 3282. 6. 296. Syphilitic Enlarg'ement of the Femur.— Upper half of a right femur — macerated, illustrating the above. There are irregular thickenings all over the shaft. These have been at one or two places the seat of destructive changes. The bone is unduly heavy: B. C. i. 5. M. 57. 6. 297. Syphilitic Enlarg'ement of the Femur.— Left femur — macerated, illustrating the above. On the inner and outer surfaces above there are nodular thickenings, which are continuous with one another on the 320 Diseases of Bone. lower third. The surface of the inner of the two nodes is the more porous and irregular, B. C. i. 5. M. 56. jj 6. 298. Syphilitic Enlargement of the Femup.— Posterior lialf of the upper end of a left femur — macerated, illustrating the above. On the shaft there is an irregular thickening, which, as the section shows, is chiefly of cancellated tissue. The medullary cavity seems somewhat enlarged. W. C. G. 21. a. 6. 299. Syphilitic Enlargement of the Femur.— Sections of the upper end of the shaft of a right femur — macerated, illustrating the above. There is great thickening of the surface, especially on the inner side. The section shows that the enlargement has a compact outer wall and a cancellated interior. The original comj)act layer of the shaft of the bone is still traceable, although about the middle of the enlargement it has been opened out. W. C. G. 21. a. 6. 300. Syphilitic Enlargement of the Femur. — Lower end of a left femur in section — macerated, illustrating the above. The bone is thickened all round, a little way above the condyles. The section shows that the new bone is much con- densed behind, but less so in front, and that the medullary cavity at the seat of the thickening has been occupied by newly formed cancellated tissue. B. C. i. 5, M. 5. 6. 301. Syphilitic Enlargement of the Femur.— Anterior half of a left femur — macerated, illustrating the above. Syphilitic Enlargement. 321 A large node extends along the inner surface in the form of a diffused periosteal thickening, somewhat uneven on the surface. The interior of the node is compact and continuous with the shaft above, but elsewhere it is more or less cancellous where it lies on the shaft. "W. C. G. 21. a. 6. 302. Syphilitic Enlarg-ement of the Femur.— Posterior half of the lower end of a left femur — macerated, illustrating the above. The surface is irregular, from a deposit of condensed bone upon the compact shell, i^ear the lower end the process has been recent, and a film of new periosteal bone on the surface of the old thickening is clearly distinguishable at the inner part of the section. W. C. G. 21. a. 6. 303. Syphilitic Enlargfement of the Femur.— Posterior half of the middle three-fourths of a left femur — macerated,, illustrating the above. A large node is seen in section on the inner surface. It is condensed, except about the middle, where the tissue is more porous. The line of the original compact shell can, however, still be traced. W. C. G. 21. a. 6. 304. Syphilitic Enlarg-ement of the Femur.— Sections of upper end of a right femur — macerated, illustrating the above. The surface is irregular from the formation of new densely compact bone, continuous with the original compact tissue, and indistinguishable from it. This condensation often goes by the name of sclerosis. The medullary cavity is somewhat contracted. P. P. C. 393 and 394. Presented by Professor John Thomson. X 322 Diseases of Bone. 6, 305. Syphilitic Enlargfement of the Femur.— Section of a femur — macerated, illustrating the above. The surface is irregular and the interior greatly condensed or sclerosed. F. P. C. 408. Presented hy Professor John Thomson. 6. 306. Syphilitic Enlargrement of the Femur.— Right femur, lower end in section — macerated, illustrating the above. There are two enlargements of the bone, one on the upper half, the other on the lower half of the shaft, but they are dis- connected at the middle. The lower is the larger. Although its surface is rough, the bone forming it is much condensed. B. C. I. 5. M. 52. 6. .307. Syphilitic Enlarg-ement of the Femur.— Left femur, from the same subject as the last — macerated, illustrating the above. The bone is increased in weight and is thickened, espe- cially towards its lower end. The thickening extends all round the bone at the junction of the lower and middle thirds. Above the first thickening, and separated from it by a small area of almost unchanged bony surface, there is another, a little below the small trochanter. The surface of the upper thick- ening is porous, but that of the lower one is smooth. The apertures for blood-vessels are greatly enlarged above the lower articular surface. B. C. i. 5. M. 54. 6. 308. Syphilitic Enlargement of the Femur.— Right femur — macerated, illustrating the above. The bone is condensed and heavy, and the surface irregu- larly thickened. A small bony spicule projects upwards from the linea aspera, where it branches to pass to the inner condyle. F. P. C. 636. Fresented hy Professor John Thomson. Syphilitic Enlargement. 323 6. 309. Syphilitic Enlarg-ement of the Femur.— Right femur — macerated, illustrating the above. The bone is heavy, and the surface shows at various places ■diflfused thickenings, with marks of increased vascularity. The neck is short, and the head, owing to absorption, is below the level of the trochanter. The margins of the articular surface are prolonged and overhang the neck — changes often seen in arthritis deformans. Sir Charles Bell notes : " The sinking of the head of the bone and distortion of the neck have been consequent on disease. An appearance is presented in the specimen which has been described by some as a reunited fracture within the capsular ligament." Probably syphilis has altered the shaft, and arthritis deformans the upper end. B. C. i. 1. M. 22. a. 6. 310. Syphilitic Enlarg-ement of the Tibia. Eight tibia of an adult, from the same syphilitic subject as that from which !Nos. 6. 306 and 6. 307 were taken — macerated, illustrating the above. There is an enlargement on the outer surface, three or four inches from the lower end, and a periosteal crust extends on the shin surface as high as the upper third. An elongated patch of new periosteal bone is seen on the outer surface, at the attachment of the tibialis anticus. The bone is some- what increased in weight. B. C. i. 5. M. 53. 6.311. Syphilitic Enlargement of the Tibia.— Left tibia, from the same subject as the last — macerated, illustrating the above. There are periosteal crusts on the shin surface, and also at the upper part of the outer and posterior surfaces. The bone is also somewhat increased in weight. B. C. i. 5. M. 55- 324 Diseases of Bone. 6. 312. Syphilitic Enlarg-ement of the Tibia.— Right tibia —macerated, illustrating the above. There is a comparatively new periosteal node or enlarge- ment on the posterior and inner surfaces, near the upper end^ with marks of increased vascularity on the outer surface lower down. The bone is somewhat increased in weight. B. C. I. 5. M. 72. 6. 313. Syphilitic Enlargement of the Tibia.— Left tibia — macerated, illustrating the above. There are two distinct nodes on the shaft, — one small, on the anterior ridge two inches below the tubercle, and the other, much longer and larger, on the posterior and inner surfaces, about the middle. A slight periosteal crust is seen just beside the outer tuberosity, on the outer surface. The bone is increased in weight. "W. C. G. 40. 6. 314. Syphilitic Enlargement of the Tibia. — Lower half of a right tibia — macerated, illustrating the above. A large periosteal node occupies the greater part of the inner surface, and extends to the back and outside. Its surface is porous, as if the process had been still active. The bone is somewhat increased in weight. B. C. i. 5. M. 76. 6. 315. Syphilitic Enlargement of the Tibia.— Left tibia- macerated, illustrating the above. The posterior and outer surfaces are thickened and rough- ened from new periosteal formation. The lower end of the bone and the front and upper parts of the shin surface are comparatively unchanged. This condition resembles the nodes seen in previous specimens, only more diffused. The bone is a little increased in weight. B. C. I. 5. M. 71. Syphilitic Enlargement. 325 6. 316. Syphilitic Enlargement of the Tibia.— Left tibia- macerated, illustrating the above. The anterior and lateral parts of the bone are diffusely thick- ened, except near the upper and lower ends. There are also one or two thickenings on the posterior surface. The surface of the main thickening is rough and porous, except over an area on the inner side, about five inches from the lower end, where it is smooth. B. C. i. 5. M. 74. 6. 317. Syphilitic Enlargrement of the Tibia.— Left tibia- macerated, illustrating the above. There is one periosteal node on the outer and inner surfaces about the middle and another smaller one on the posterior surface higher up. The surfaces of the nodes are smooth as if the active process had long ceased. The inner surface at the lower end shows marks of increased vascularity, and the bone as a whole is increased in weight. B. C. I. 5. M. 68. 6. 318. Syphilitic Enlargement of the Tibia.— Right tibia of a strong man — macerated, illustrating the above. This specimen was from the same skeleton as No. 6. 293, -which see. There are nodes on the posterior surface, and a smaller one on the crest, as well as a periosteal crust on the shin. There are several marks of pick and spade on the bone, which were produced when it was being dug up. G. C. 3276. Presented by W. R. Martine, M.B. , CM. 6. 319. Syphilitic Enlargement of the Tibia.— Left tibia from the same skeleton as the last — macerated, illustrating the -above. 326 Diseases of Bone. There are diffuse i^eriosteal thickenings along the posterior and inner surfaces, and slightly also on the outer surface near the lower end. The surface of the nodes is at some places rough and at others smooth, as if a disease of long standing were still progressing at places. There is a mark of the pick near the lower end. G. C. 3277. Presented by W. R. Martine, M.B., CM. 6. 320. Syphilitic Enlargrement of the Tibia.— Shaft of the right tibia of what must have been a strong man, illustrating the above. It was also found beneath the floor in Haddington Parish Church. (See No. 6.293.) There has been such extensive periosteal new formation that very little of the surface of the bone is unchanged. There- are marks of the pick at various places. G. C. 3278. Presented by W. R. Maetine, M.B., CM. 6. 321. Syphilitic Enlarg-ement of the Tibia.— Shaft and lower end of a left tibia, apparently of a middle-aged man or a tall woman. The bone was found beneath the floor in Haddington Parish Church. (See No. 6.293.) There is a smooth node about the middle of the shin surface. The pick has marked the bone above the lower end. G. C. 3279. Presented by W. R. Maktine, M.B., CM. 6. 322. Syphilitic Enlarg'ement of the Tibia.— Left tibia, apparently of a woman — macerated, illustrating the above. There are irregular nodes on the surface of the greater part of the shaft, especially at the upper end. B. C. I. 5. M. 75. Syphilitic Enlargement. 327 6. 323. Syphilitic Enlargfement of the Tibia.— Left tibia- macerated, illustrating the above. About the middle there is a considerable thickening, the surface of which is smooth behind, but irregular and porous on the inner side, B. C. i. 5. M. 70. 6. 324. Syphilitic Enlargrement of the Tibia.— Middle third of a left tibia — macerated, illustrating the above. There is a considerable periosteal thickening on the inner and posterior aspects, and its surface is rough and porous all over. G. C. 1006. 6. 325. Syphilitic Enlargement of the Tibia.— Left tibia — macerated, illustrating the above. A churchyard specimen. The shaft is encrusted with periosteal bone all over, but especially along the back, and near the lower end of the inner surface, where a node has been developed. The surface of the new bone is partially destroyed, probably from its having been buried. B. C. i. 5. M. 49. 6. 326. Syphilitic Enlargrement of the Tibia.— Left tibia- macerated, illustrating the above. The whole of the bone from the upper third to within an inch of the lower articular surface is thickened by periosteal deposit, especially on the anterior and lateral aspects. The surface of the enlargement is unusually irregular, and at places has been rarefied and eroded. The bone is increased in weight. G. C. 1005. 6. 327. Syphilitic Enlarg-ement of Tibia and Fibula.— Lower halves of a right tibia and fibula — macerated, illustrating the above. 328 Diseases of Bone, The leg was amputated. The fibula is for the most part covered with a nodular crust of new bone, the surface of which is rough, especially near the lower end. The tibia, several inches above its lower end, shows a similar crust, especially at the back, but towards the middle of the shaft the changes are comparatively slight. F. P. C. 449. Presented by John Campbell, F.R.C.S.E. 6. 328. Syphilitic Enlarg-ement of the Bones of the Leg. — Left tibia and fibula — macerated, illustrating the above. The tibia has a periosteal crust over nearly the whole of its surface, especially towards the lower end, where the bone is manifestly thickened. The surface of the thickening is smooth on the inner aspect and rough on the outer. The fibula shows irregular periosteal deposits over the greater part of its svirfaces. The bones are increased in weight. B. C. i. 5. M. 73. 6. 329. Syphilitic Enlargrement of the Fibula.— Portion of a fibula — macerated, illustrating the above. The shaft is thickened for about three inches by a fusiform node-like development of bone upon its surface. F. P. C. 459. 6. 330. Syphilitic Enlargrement of the Fibula.— Right fibula — macerated, illustrating the above. The lower half of the bone is uniformly thickened all round, and its surface is rough and porous, with patches of rarefaction and erosion here and there. B. C. i. 5. M. 83. 6. 331. Syphilitic Enlargrement of the Fibula.— Shaft of a left fibula — macerated, illustrating the above. Syphilitic Enlargement. 329 There is a periosteal node near the loAver end, which is porous and eroded on its outer surface. B. C. i. 5. 'M. 85. 6. 332. Syphilitic (?) Enlargement of the Fibula.— Lower end o± a left fibula — macerated. There is much new periosteal formation upon its inner surface, with rarefaction at one place. B. C. i. 5. M. 84. 6. 333. Syphilitic (?) Enlarg-ement of the Fibula.— Left fibula — macerated. There is much irregular periosteal formation on its anterior and outer surfaces, near the middle third. W. C. G. 16. 6. 334.' Syphilitic (?) Enlapgement of the Fibula.— Left fibula — macerated, showing great irregularity and enlargement at the malleolus. This may have been possibly from syphilis, possibly from tubercular and septic disease of the ankle. B. C. ii. M. 42. 6. 335. Congenital (?) Syphilitic Enlargement of the Tibia. — Section of a right tibia, injected Avith carmine and in spirit. "J. E., £et. 22, was admitted to the Eoyal lufirmary under Dr P. H. MacLaren's care, suffering from necrosis of the bones of the forearm, diagnosed to be syphilitic in character. For this condition the forearm was amputated through the upper third on 19th April 1887. The wound healed well. Shortly afterwards at the upper part of the tibia a gumma formed, which softened and burst, leaving an ulcer with bare bone at its base. Another similar ulcer soon formed at the lower end of the tibia. For these the patient was again admitted to the Royal Infirmary in June 1887. Both ulcers continued discharging, in spite of treatment, and without any indication of the separation of the necrosis. As the continued discharge was weakening the patient, the leg was amputated through the lower third of the thigh by Dr MacLaren on 8th November 330 Diseases of Bone. 1887. Although no history of syphilis, congenital or acquired, could be obtained, the syphilitic nature of the disease was diagnosed from the course of the symptoms, and it was considered to be probably congenital." The whole of the bone is enlarged by the formation of cancellated tissue. At the upper end there is a section of the necrosis, and its white, non-vascular character is brought out in contrast with the surrounding injected bone. Round the surface of the necrosis there was an ulcer of the skin, part of which has been left. Part, however, has been removed, to show patches of caseous material, which had been present in the periosteum outside the base of the ulcer. A certain amount of separation of the necrosis had occurred, but not enough to loosen it. Several white caseous deposits are seen in the interior of the bone, above the necrosis, and one or two are seen near the anterior surface at the lower end. On the soft parts, near the lower end, a large gumma is shown, caseous and non-vascular, and surrounded by an area of increased vascularity. In front of this a small sinus in the skin has been left, and the soft parts removed near it, to show that it led down to a gummatous deposit in the periosteum. G. C. 2770. Presented by P. H. MacLaren, F.R.C.S.E. 6. 336. Syphilitic Enlarg"ement of the Tibia.— Upper end of a right tibia — macerated. There is a deposit of periosteal new bone on the surface.. The bone is increased in weight. F. P. C. 446. 6. 337. Congfenital Syphilitic Nodes on the Lower Ends of the Tibia and Fibula. — Plaster cast of the left leg and foot of the boy from whom the cast 'No. 6. 295 was taken. The cast shows a swelling due to enlargement of the lower ends of the tibia and fibula, just above the ankle. G. C. 3283. Syphilitic and Septic Disease. 331 7. Inflammation of Bone due to Syphilis, complicated hy Sepsis. 6. 338. Syphilitic (?) Disease of the Tibia and Invasion by an Ulcer. — Portion of a right tibia — macerated, illustrating the above. Nearly all round the bone there is a thickening, which, to judge from the rarefaction on its inner surface, has probably formed the base of an ulcer. B. C. i. 5. M. 6. 6. 339. Syphilitic (?) Disease of the Tibia and Invasion by an Ulcer. — Lower end of the right tibia of a young man- macerated. The epiphysis has not yet united. There is an enlargement on the inner aspect near the lower end, and the surface there is rarefied and depressed, as if it had formed the base of a deepening ulcer of the soft parts. This specimen has been considered syphilitic from the node-like character of the swelling, the comparative youth of the patient, and the absence of such surrounding periosteal new formation as is commonly associated with ordinary ulcera- tion. B. C. I. 5. M. 65. 6. 340. Syphilitic Disease of the Tibia, with Invasion by an Ulcer. — Portion of a left tibia — macerated, illustrating the above. On the shin surface there is a node, which is excavated and rarefied as if it had formed the floor of an extending ulcer of the soft parts. Some new periosteal bone has been formed up and down the shaft near the ulcer. G. C. 1007. 6, 341. Syphilitic Disease of the Tibia, with Invasion by an Ulcer. — Eight tibia of a tall young man, with the epi- physis not yet united — macerated, illustrating the above. 332 Diseases of Bone. The lower part of the tibia shows a node-like thicken- ing which extends nearly all round. The thickening rises abruptly from the surrounding bone above. Its surface is rough and porous, as if it had formed the base of an extending ulcer. One or two smaller nodes may be seen above the large one. The bone is unusually light. The grounds for believing this to be a case of syphilis are the presence of the nodes, and of so large an ulcer in so comparatively young a person. (See No. 6. 339.) G. C. 1179. Fresented hij Professor James Russell. 6. 342. Syphilitic Disease of the Tibia, probably com- plicated by Ulcers. — Left tibia of an adult in section — macerated, illustrating the above. On the inner or shin surface there is a smooth node-like swelling above the middle, and lower down two abrupt nodes, which may have lain beneath ulcers of the skin. The upper of these two is the smaller and has a porous surface. The other larger one has its surface partly smooth and partly porous. The outer and posterior surfaces of the bone are rough and irregular. The medullary cavity is occupied by cancellous bone beneath the upper node, and at other places shows irregular dilations. These in old syphilitic bones usually contain fat, not pus or caseous matter, as might possibly be supposed. The tissue of the bone is on the whole lightened, and the compact outer layer has for the most part been replaced by cancellous tissue. B. C. I. 5. M. 78, 79. 6. 343. Syphilitic (Mercurial?) Disease of the Tibia, with Necrosis. — Right tibia and fibula — macerated, illustrating the above. This was formerly described as "tibia and fibula of the right leg of a person affected with syphilis. The disease continued for twelve years, during the greater portion of which time mercury was taken." Syphilitic and Septic Disease. 333 A large and very irregular piece of bone on the shin surface has proTbably been exposed on the floor of an ulcer. It is deeply entrenched all round except at the upper end. An aperture on the oblique ridge behind exposes the necrosed bone at the back, but the deep attachments are otherwise still quite firm. The general surface of the shaft is very rough from new periosteal formation. At the lower end the inner and posterior surfaces are greatly eroded, and show apparently a necrosis of the interior, which has extended to the outer part of the articular surface. The fibula is unchanged, with the exception of a new periosteal deposit on the surfaces adjacent to the tibia. F. P. C. 447. Presented by Professor John Thomson. 6. 344. Syphilitic (Mercurial ?) Disease of the Tibia, with Necrosis. — Left tibia and fibula from the same patient as the last — macerated, illustrating the above. There are two partially separated necroses — one just above the middle, distinctly entrenched round but still adherent ; the other above the lower end, much rougher on its surface, and less distinctly entrenched below, where it merges 'into a carious condition of the surrounding bone. The rest of the tibia is thickened by new periosteal bone, with a porous surface. The lower articular surface of the tibia is affected apparently by necrosis of the bone over an area corresponding to that on the right side but less advanced. The upper articular surface is unchanged. This fibula, like the right one, is comparatively unchanged. F. P. C. 448. Presented by Professor John Thomson. 6. 345. Syphilitic (Mercurial?) Disease of the Tibia, with Necrosis. — A right tibia in section — macerated, illustrating the above. 334 Diseases of Bone. A large mass of rough, and irregular bone near the middle of the shin surface has apparently been a sequestrum in process of separation, and has no doubt lain exposed on the floor of an ulcer. Below this the bone is porous, as if it had formed the base of an extending ulcer, and below this again there is a raised mass of periosteal bone, which is penetrated here and there by roughened apertures. The rest of the surface of the tibia is rough from new periosteal bone formation. The section of the bone shows a small central necrosis near the upper end. Above this piece there is an excavation of the head of the tibia, and below it the greater part of the medullary cavity is occupied by cancellated tissue. G. C. 1179. a. Presented by Professor James Ritssell. 8. Goiiibinecl Effects of St/philis and Rickets. 6. 346. Syphilis and Rickets of the Femur.— Left femur of an adult — macerated, illustrating the above. The specimen shows a rickety bend, with syphilitic nodes on the surface. The bend is chiefly seen at the upper end, and is an exaggeration of the normal curve, such as is usually seen in rickets. The nodes occupy the front and outer part of the shaft, and bear a close resemblance to the syphilitic nodes seen in previous specimens. B. C. i. 5. M. 51. 6. 347. Syphilis and Rickets of the Femur.— Right femur- macerated, illustrating the above. The normal bend of the shaft is exaggerated above, and a node has apparently been developed about the same place. This somewhat resembles the previous specimen, and may be considered to have been a slight case of rickets to which syphilis has been superadded. F. P. C. 603. Presented by Professor John Thomson. Fungus Foot of India. 335 9. Inflammation of Bone due to Actino- Mycosis. 6. 348. Actino-Mycosis of Bone.— Section of the jaw of an ox, illustrating the above. From a slaughter-house in Berlin, where this disease is said to be comparatively common in summer. The bone has been irregularly enlarged, and. is occupied by numerous cavities of varying size containing a caseous-looking material. The bone between these cavities is firm and dense. G. C. 3387. Presented by Edgar "Willet, F.R.C.S. Eng. 10. Inflammation of Bone due to the Mycetoma Fungus. 6. 349. Mycetoma or Fung-us Foot of India— Black Variety. ' — Foot of a Hindoo, aged 40, in section — mounted in spirit, to illustrate the above. "1877, July 14. — Admitted on the 8th inst. for the above, which is of ten years' duration. Before the disease manifested itself used to work in the iields, the soil of which was not black cotton, but the ordinary red soil of the country. Had no guinea-worm ; not pricked by a thorn. "The foot is now enormously swollen, especially in its posterior two-thirds. The anterior part is narrow and contracted, due to the three last toes being turned upwards, their plantar surfaces looking directly outwards and forwards, caused by his resting the foot on the outer border, and the pressure gradually raising the toes upward. There is a largish tumour on the sole, at the base of the great toe, the under surface of which is ulcerated. Characteristic tubercles are formed all over the foot, and even up the leg as far as the upper third. The leg is slightly swollen. There is a good deal of pain, attended with a burning sensation in the affected limb. The tubercles discharge sago-like granules of a black kind. His health is fair." The interior of the bones, as well as the soft parts, are occupied by characteristic black granules of varying size. These lie in spaces which formerly contained fluid, and which are surrounded by more or less complete fibrous capsules. G. C. 2511. Presented by Surgeon Tyreell, H.ll. Madras Army. 336 Diseases of Bone. 6. 350. Mycetoma or Fungus Foot of India— Yellow Variety. — Foot of a Hindoo, aged 40, in section — mounted in spirit, to illustrate the above. "1877, Jidy 7th. — Admitted into Hospital on the 21st June, States that about fourteen years ago a small movable tumour appeared over the joint of the right great toe. It gradually enlarged, and suddenly one day he found a small opening on its upper surface, which, on being squeezed, discharged blood and matter, and reddish grains like granules of soda. Soon after, others of the same character appeared all over the dorsal aspect of the sole of the foot. "When these button-like tubercles were enlarging, pain was severe, and as soon as they burst and discharged their contents he obtained relief, which was absent so long as the tubercles were empty ; but as they began to enlarge, the pain also appeared, and gradually increased in severity with the enlargement. Never worked in black cotton soil, was never pricked with a thorn, and has not suffered from guinea-worm." The foot, especially towards the front, has been enormously- swollen, and the surface, especially of the dorsum, is studded over with rounded tubercles of varying size. The interior of the front of the foot has been converted into a large cavity which contained a clear fluid, and in which the metatarsal bones are lying macerated and loose, their substance being rarefied and more or less absorbed. The soft parts are tunnelled in various directions by channels leading from the interior to the tubercles on the surface, and containing in many places characteristic yellow granules. G. C. 2509. Presented by Surgeon Tyrrell, H.M. Madras Army. 6. 351. Mycetoma or Fung-us Foot of India— Yellow Variety. — Foot of a Hindoo, aged 45, in section — mounted in spirit, illustrating the above. *' 1877, ^pril 20th. — A professional beggar admitted yesterday for the above, which is of ten years' duration. It appears that at the befrinning he noticed a white patch on the sole of the foot, which was caused by the pressure of the stilts which he used in his professional capacity. After some years the patch presented a series of fissures, from which a glutinous discharge exuded, and which adhered to his sandals. "After the application of the tlesh of squirrels as a poultice, the fissures enlarged, and from them white sago-like grains were often dis- charged. Slowly the border of the foot began to enlarge, and at the seat of the enlargement the tubercles or button-like projections so character- Mycetoma. 337 istic of mycetoma appeared one after the other, and from the apices of each, through the minute opening situated thereon, these grain-like masses were 'discharged. "A year ago the enlargement became very marked, and since then lias become enlarged, attended with pain. After the discharge of the granules, the pain, which increases until then, becomes less, and he gets •relief until the tubercles are again ready to discharge. " He is anxious to have the foot removed, "Has never been in black cotton soil ; has never had guinea worm. Some ten years previous to the appearance of the white patch, he was pricked by a thorn in the sole, near the middle of the bases of the toes. After that he was laid up for a month. Through the opening a slough was discharged, and the granulations were exulcerant, which were destroyed by some caustic application. "He was only able to walk three months after the receipt of the injury." In this specimen the front of the foot has been distended €ven more than in the previous case, and the bones have beep more extensively affected. The tubercles on the surface are fewer and smaller. There are few tunnels to be seen, and granules only here and there. G. C. 2510. Presented by Surgeon Tyrrell, H.M. Madras Army. 6. 352. Mycetoma or Fungus Foot of India.— Bones of the foot and lower end of the tibia and fibula of a native, aged 30 — macerated, illustrating the above. Amputation was performed through the leg and the patient recovered. The OS calcis and astragalus are marked by numerous circular pits and erosions on their surface, some of these passing deeply into the bone, and in some places honeycombing it. At the margins of the posterior surface of the os calcis there are numerous projecting portions of new periosteal bone. The other tarsal bones have been almost entirely destroyed, and are represented in most cases by an imperfect shell containing some atrophied cancellous tissue. The bases of the metatarsal bones are in a similar condition, and in some cases the shafts also. The tibia and fibula have been attacked in a simikir way Y 338 Diseases of Bone. near their lower ends, but higher up new periosteal bone has: been developed, G. C. 3394. Presented by James E. T. Aitchison, M.D., Ciril Surgeon, India. 6. 353. Mycetoma or Fung-us Foot of India.— Bones of a right foot — macerated, illustrating the above. Patient was aged 35, Syme's amputation was successfully performed. The bones chiefly affected are the cuboid, the cuneiforms,, and the four outer metatarsals ; the latter are very greatly reduced in size, and are marked by numerous erosions. G. C. 3395. Presented by James E. T. Aitchison, M.D., Civil Surgeon, India. IV. TUMOUKS OF BONE. A. Cartilaginous Tumours — ranging from the sloivly-groiving- sijRjjle forms ivJiosc tissues are ivell clevelo2)ed, to the raindly- gr owing malignant forms whose tissues are more or less- embryonic. 6. 354. Chondroma of the Humerus. — Section of a righ humerus and of a cartilaginous tumour growing from it — in spirit. The patient, a man aged 40, had noticed the tumour growing below and external to the shoulder-joint for ten years before he consulted Mr Chavasse. It had grown steadily, and by its increase liad caused pain in his neck and forearm. During the last eighteen months the growth had been more rapid, and the surface had become irregular. Three months before the operation, softened patches had appeared at tlie lower part. One of these had given way, and an oily fluid had at first drained from it, but shortly before the operation free h?emorrhage, apparently venous, had occurred from it also. " Up to the last the affected arm, with the aid of a sling, was used for driving, and there was no deteriora- tion of the patient's general health." The upper limb, including the scapula and part of the clavicle, was removed by Mr Chavasse, according to Berger's method. The patient made an excellent recovery, and some years afterwards was known to be in excellent health. Cartilaginous Tumours. 339 The weight of the specimen after the operation was twenty- one pounds, of which about eighteen pounds would belong to the tumour. The circumference of the tumour at the widest part was twenty-eight inches. Its consistence was firm and elastic, except at one or two spots, where it had become cystic. The outline Avas nodular, and several large veins were seen on the surface. In cutting the tumour calcareous nodules were met with, so that the knife and saw had to be used alternately. The tumour consists of nodules of cartilage varying from the size of a pea to that of a walnut. The smaller nodules, when fresh, were translucent and firm like the substance of the crystalline lens. The large ones were yellowish and some- what opaque, and in some cases had softened at the centre. Kound the nodules there was a delicate stroma of connective tissue, carrying blood-vessels. From these, in some places, lime salts have been deposited, so as to form a calcareous shell round the nodules. Here and there, where several calcareous nodules have united, the interior is transformed into cancellous bone. The outer part of the shaft of the humerus is thickened and sclerosed at the upper end, but the interior is unaffected. The tumour seems to have started from the thickened part, and to have partially surrounded the humerus. Microscopically, the tumour was found to consist of hyaline cartilage without special features. For further particulars of this case see " Successful removal of the entire upper extremity for Osteo-chondroma, by Thomas F. Chavasse, M.D.," etc., in vol. Ixxiii. of the " Medico- Chirurgical Transactions of London." G. C. 3128. Presented hjT. F. Chavasse, F.R,C.S.E. 6. 355. Chondroma of the Humerus.— Portion of the same tumour — macerated, to show how the calcareous matter has been deposited as a shell round the nodules. G. C. 3177. Presented by T. F. Chavasse, F.R.C.S.E. 340 Diseases of Bone. 6. 356. Chondroma of the Humerus. — Glycerine and gelatine cast of same tumour as it was after removal. The relation of the tumour to the arm is well brought out, as well as the nodular character of the surface of the tumour, G. C. 3127. Presented by Charles W. Cathcart, F.R.C.S.E. 6, 357. Chondroma of the Humerus. — Photograph, before and after the operation, of the patient from whom the foregoing tumour was removed. Taken from Mr Chavasse's paper. (See Xo. 6. 354.) G. C. 3399. 6. 358. Chondroma of the Humerus. — Wax cast of a left humerus and attached tumour, illustrating the above. Six years before the operation the patient had occasional pains in the shoulder, and in six months afterwards he observed ou the forepart of the shoulder a firm swelling, which appeared to be seated on the bone. Three years afterwards he fell and broke the affected humerus about the middle, but it united without displacement. "But the morbid growth advanced more rapidly after this injury, and his uneasy sensations kept pace with its progress. He said that what chiefly distressed him latterly was a feeling of weight and oppression which never ceased, and was particularly severe during the night. He had no other complaint, and seemed to be sound in all other respects." Before the operation the following description was drawn up : — " It had a verj- broad base, which completely filled the axilla, and seemed to grow out from the side of the thorax. The shoulder-joint did not admit of any motion, but the arm moved freely along with the scapula. The head of the humerus seemed to be the centre of the swelling, which extended from it in every direction, terminating about half-way from the elbow, and approaching within two inches of the sternum. The clavicle and spine of the scapula could be traced nearly, but not quite, to their junction. The consistence of the tumour was extremely firm, feeling in some parts as if it were composed of bone, and in others of fibro-cartilage. The surface appeared in general pretty equal, but when examined more carefully was found to be irregularly nodulated. The colour of the integuments was not altered." The tumour was removed, along with the glenoid cavity and the Cartilaginous Tumours. 341 acromion and coracoid processes of the scapula and part of the clavicle. The patient made an excellent recovery. The tumour weighed twelve pounds. It was macerated, but all the parts fell to pieces. This has probably been a case like the previous one, and the nodular character of the cast still further confirms this view. G. C. 1789. Presented hy James Syme, F.R.C.S.E. 6. 359. Chondroma of the Humerus. — Photograph of Mr Syme's illustration of the patient from whom the above tumour was removed. G. C. 3400. 6. 360. Chondroma (?) of the Humerus.— Plaster cast of a large tumour, apparently of the upper end of a left humerus, to illustrate the above. Prom its nodular character and position, it has probably been a tumour similar to the two previous ones. P. P. C. 2920. 6. 361. Chondroma of Thumb and Forefinger.— Sections of cartilaginous tumours growing from the metacarpal bone of a thumb and the first phalanx of a forefinger — in spirit. The patient, when a boy, had his hand crushed, and afterwards the tumours formed gradually. The sections show that the tumours are composed of numerous small lobules of hyaline cartilage, each apparently surrounded by a very delicate stroma. Some of the nodules seem to have been softening. The surface of each tumour is formed by a thin layer of bone continuous with the bone from which the tumour has grown. Imperfect and irregular appearances of septa are seen here and there passing inwards from the interior of the bony shell. B. C. i. 6. M. 32. 6. 362. Chondroma of Little Finger.— Metacarpal bone and 342 Diseases of. Bone. first phalanx of the little finger of a left hand — macerated, illustrating the above. An expanded shell attached to each bone is evidently the remains of a cartilaginous tumour. That on the metacarpal bone is the more complete, and has arisen from the back of the bone, at its phalangeal end. It forms nearly a complete shell, but is perforated and deficient here and there. The interior has, attached to the wall, numerous irregular processes or septa, which before maceration must have separated cartilaginous nodules. The expanded part on the phalanx has been partly sawn away, but it has originally been less complete than that on the metacarpal bone. The interior of the phalanx is quite exposed. This specimen was formerly described as a case of " spina ventosa." G. C. 205. 6. 363. Chondroma of Little Fingep.— Phalanges of what seems to be a little finger, apparently of a young person, with chondroma arising from the first phalanx — in spirit. Amputated at St. George's Hospital, and presented to Mr Wilson by Mr Brodie in 1806. An extension from the back of the first jihalanx passes for a short distance on to the surface of the tumour, the interior^ of which is composed of small lobules of hyaline cartilage, now rendered very opaque by the spirit. Formerly described as tumour of first phalanx of thumb. W. C. G. 32. a. 6. 364. Chondroma of Fingers.— Plaster cast of a left hand, apparently of a woman, illustrating the above. There are tumours upon all the phalanges and upon some of the metacarpal bones. The largest one, which is on the middle finger, has attained the size of a small orange. Those on the index finger are next in size, and extend nearly to the tip. The third finger is least affected, but shows distinct Sarcomatous Cartilaginous Tumours. 343 enlargements. The first, second, and fifth metacarpal bones have had small growths attached to them. G. C. 2269. 6. 365. Chondro-sarcoma of the Thumb.— Section of a thumb — in spirit — showing a chondro-sarcomatous tumour growing from the first phalanx. The man, aged 51, was admitted to the Royal Infirmary, Edin- burgh, in December 1891. His family history was good, and he had previously been quite healthy and temperate. "Seven years ago," while holding a horse with a rope, the rope got twisted round his thumb and hurt it. The thumb was sore for several days after this, but did not swell. This was in spring ; during the summer it felt stiff, and in the following winter the first phalanx swelled up from what was considered to be rheumatism. During the following winter it again became at times sore and swollen. The swelling was red, and the veins over it were distended. It came and went more frequently, and seemed to be worse on exposure to cold. It soon continued lo be painful even when there was no swelling. This intermittent swelling continued for four years, when he noticed a small lump attached to the outer side of the first phalanx. The lump was bluish and soft ; it ■was very painful, and he thought it was going to form matter. It, however, continued to grow without coming to a head. Eighteen months :ago it was opened, and only blood came out, and last August it was opened again, with the same result. The thumb was amputated and the patient shortly afterwards went home. After section the tumour was found to have originated in the front of the first phalanx, and to have expanded the bone for a short distance laterally, but there was no shell of the bone over the main piece of the tumour. The joints at each end of the phalanx were not affected. The tumour mass was of firm consistence, except towards the margins, where it was soft and reddish, haemorrhages having taken place into the tissue at these parts. The main mass of the tumour presented a gelatinous appearance, with a network of dense white material, apparently cartilage of firmer consistence than the rest, and with calcareous nodules interspersed. Microscopic examination showed it to be chondro-sarcoma (round-celled) with some myxomatous degeneration. G. C. 3358. Presented hy John Duncan, F.R.C.S.E., December 1891. 344 Diseases of Bone. 6. 366. Chondro-Sarcoma of the Thumb.— Plaster cast of the hand from which the previous specimen was taken. The size and position of the tumoiir is well shown. G. C. 3357. Presented hy Charles W. Cathcart, F.R.C.S.E. 6. 367. Chondro Sarcoma of Scapula and Chondromata of Fing"ers and Humerus. — Right arm, with scapula and part of clavicle amputated for enormous chondro-sarcoma of the scapula — in spirit. The patient was a gentleman, aged 33. From infancy the joints- of both arms were noted as "peculiar." The shonlder, elbow, and finger joints of his right arm were supposed to have been "put out" by some injury, of which, however, no history was obtainable from his mother. During childhood and boyhood the finger-joints steadily got more "peculiar," enlarging gradually till, when he was 18 years of age^ the growths formed a decided inconvenience, particularly those on the right hand, all the fingers of which were affected. On the left hand, the middle, ring, and little fingers only had growths. As the tumour of the right middle finger hindered him from writing, the finger was removetl by Professor Syme. The patient was at this time fully engaged in hard office work. In 1870, when about 20 years of age, he went to Southern India, and remained there for thirteen years, enjoying, until the growth of the great tumour, perfect health. He was able to write, ride, and play lawn tennis. The growths on his fingers had meanwhile only slightly increased up to about January 1883 (the year of the operation). He then began to feel pain in the right shoulder, and was treated for neuralgia. The pain got worse ; the shoulder began to swell ; his clothes required altering,, and finally he had to keep his arm in a sling outside of his clothes altogether. The pain centred over the bicipital groove and was very much aggravated by the least pressure. By April 1883 he had gradually become invalided, the pain getting steadily worse. He walked with diflBculty, till in July he was forced to lie up. After a month in bed he could only stand with help. In August he was carried to Madras for further advice. At this time he could straighten his legs, but the growth was increasing rapidly. At Madras he was advised to return home, and did so, being carried into hi& bunk in October, and never leaving it during a voyage of thirty days. Being a tall man, his legs were kept permanently bent up, thus acquiring the position described in "present condition." On arriving in Edinburgh he saw Dr Gillespie. Dr Patrick Heron Watson was shortly afterwards called in consultation, but thought that any operation was inadvis- able, because the patient's general health was in such an unsatisfactory condition. Sarcomatous Cartilaginous Tumours. 345 By 17th December his general condition and blood had consider- ably improved under treatment, and Dr Watson decided to remove the arm, scapula, enter third of the clavicle along with the tumour, as the only possible means of affording relief to the patient's intense sufferings. He was in a state of constant acute suffering, and could not retain the arm for five minutes in one position. The pain prevented the possibility of sleep for more than three minutes at a time, and he had not slept an hour for many weeks. He liad quite a cachetic appearance. At this time the tumour of the right scapula rose as a great hump above the line of his shoulder. It was incorporated with the scapula and adjacent parts. It was firm in consistence in some places, and soft and almost fluctuating in others. There were also multiple growths, like small apples and firm in consistence, on the metacarpal and phalangeal bones of both hands. The knees were rigidly semi-flexed, and the patient had scarcely any power over his lower limbs, the muscles of which were much atro- phied. The thighs and calves felt brawny. Dr "Watson operated on 17th December 1883, and the wound healed without a bad symptom. Although he made a capital recovery as to wound, he only slowly recovered the use of his legs, by the use of rubbing, the "battery," and extension at night to straighten the knees. On 6th April 1884 his general health was good, but as he was still unable to use his 4egs, much the same treatment was continued. On 20th June 1884 a photograph of the cicatrix was taken. He could then walk with help, and his health was good. During July and August he walked fairly well, and went to the country. In September, on his return, he did not look so well, his colour being dusky. In November 1884 Dr Burn Murdoch was called to attend him for pains in his chest on the right side, with short- ness of breath and cough. Some pleuritic rubbing was heard, and a copious efi'usion into both right and left pleural cavities was detected. He died shortly afterwards, in November 1884, from obstruction to respira- tion and increasing weakness. Autopsy. — The chest (both sides) was full of fluid, and both lungs were studded over with hard and semi-hard nodular masses. One or two nodules of a similar nature were found on the internal surface of the ribs. (Permission had been given to examine the chest only. ) The fingers are disfigured by numerous simple cartilaginous tumours of the usual character. A section of one has been made to show its structure. The firm lobulated cartilaginous substance, interspersed with calcareous and osseous nodules, is characteristic of the slow-growing simple chondroma. A somewhat similar tumour can be seen growing from the outer condyle of the humerus, as well as from the adjacent portions of the bone. The tumour on the scapula has been sliced in one or two places 546 Diseases of Bone. to show its character. It is formed of large masses, surrounded by fibrous tissue. The interior of these masses is broken up into small portions, apparently by the softening of the matrix, so that the tumour has an irregular, honeycombed appearance, which is a great contrast to the firm texture of the chondroma of the fingers, placed in juxtaposition to it. Microscopically this tumour consists of a substance resembling embryonic cartilage, showing numerous spindle cells, with a relatively small proportion of inter-cellular substance. G. C. 2726, Presented hy Patrick Herox Watson, F.R.C.S.E. 6. 368. Chondro-Sarcoma of Scapula and Chondromata of Fingers and Humerus. — Photograph of the cicatrix about six months after the removal of the above tumour. Taken 20th June 1884. G. C. 3401. Presented hy T. Burn Murdoch, M.D. 6. 369. Chondro-Sarcoma in Lung".— Portion of lung from previous case — in spirit. Nodules of chondro-sarcoma are scattered through the lung substance. The nodules on section show a naked-eye appear- ance similar to that seen in the large tumour of the scapula. Microscopically also the characters are the same as those of the original tumour. G. C. 3184. Presented hy T. M. Burn Murdoch, M.D. 6. 370. Chondro-Sarcoma of Humerus. — Section of what had been an enormous tumour — in spirit, illustrating the above. John Bell called it an " osteo-sarcoma arising from the humerus." Sarcomatous Cartilaginous Tumours. 347 The following historv- of the case is taken from John Bell's "Principles of Surgery," vol. iii. part i. page 82 : — "Alexander Macdonald, a Highlander, from Fort Augustus— a tall and handsome lad, passing six feet in height, and uncommonly athletic— was put to the Perth Academy for his education in writing, book-keeping, and such other parts of learning as might qualify him for a counting- house. It was intended to send him to America, a clerk to the North- West Company, in the fur trade. In running violently at tennis, in the Academy green, he fell and hurt his shoulder. It was such a bruise as often happens from a fall, without entailing the slightest ill consequence beyond the first pain and swelling ; the skin was blackened by the bruise and the joint was sprained ; he had excessive pains along the whole arm for twenty-foar hours ; but it vanished gradually. He imagined himself well ; he had recovered everything but the strength of his arm ; but after the violence of the pain (which lasted no more than twenty-four hours) was gone, such weakness remained, that though from his great strength he could lift perpendicularly such weights as others could not move, yet he could never raise his arm to his head. "I was at pains to question his father, a respectable old man, concerning the part which received the injury, and he clearly and decidedly affirmed that it was not the shoulder-joint, but the middle of the bone of the arm that received the shock. It was along the whole of the arm that he felt the pain, and could distinguish the marks of the bruise. The pain had, after its first violence, totally ceased, as if the part had sustained no permanent injury, and he believed himself well. It was exactly at the end of a month that the pain returned and fixed in the joint, with a very distressing sense of weakness, so that he could not at all raise his arm ; if he meant to put on his hat with it, he had to raise it with the other hand, and when thus raised, if he lowered it again without support, the moment it fell unsupported below the level, it descended like lead. Still, he could lift perpendicularly a very great weight, but from this second period of pain we must date the disease. The whole arm swelled, but especially about the shoulder. His cries and shrieks were wild and melancholy. Living in a remote part of the High- lands, it is natural for the father to express himself in the following words, which he invariably uses when I question him in regard to the degree of pain : ' Sir, there was no hour of the night nor day in which you could not hear his wild cries miles off.' He represented the particular pain by saying it seemed as if he had been bored with hot irons ; and his cries were so unceasing, as well as so piercing, that ' though they lived in a very long house they had no sleep from this time forward.' " That such had been his condition no one could doubt who saw him before his death, for the swelling kept equal pace with these dreadful sufferings. At first the arm seemed chiefly to swell from the shoulder-joint ; gradually the whole arm swelled, and the forearm and hand dwindled. His body, before lusty and strong, was wasted with the agony and want of rest. Yet even at this time, when the arm was monstrously swelled, and before it was entirely oppressed, or the forearm wasted, he could 348 Diseases of Bone. lift as heavy a weight with the left arm as with the right, and even to the last stage, that in which I saw him, his hand was strong to grasp. In the first four months the upper part of the arm had so increased in size that the prominent part exceeded the size of his head, but now, at the end of nine months, it greatly exceeds in size his emaciated bod}'. ' ' When I went to receive this poor lad, I found him lying deep in the hold of a small sloop, in which he liad been transported from Inverness, laid on a coarse mattress, and bolstered up against the shelving side of the vessel ; and when the clothes were lifted I solemnly declare that I hardly knew at first what it was that I saw — which was the tumour and which his body, or how to connect in imagination the one with the other. He lay in an inclined and irregular posture, extremelj' languid, and hardly able to articulate, his head inclining to one side. The tumour, when first exposed by lifting the clothes, might be mistaken for his body in respect of size, it was of a suitable bulk, and when the lean, yellow, emaciated thorax was next exposed, the tumour seemed so much to exceed it in size, with a shining surface and brilliant colour, that at first I was more confounded than shocked, so impossible was it, in the first moments, to consider of it as a tumour, or to see its relation to the arm. The forearm was dwindled and shrunk, and projected from the tumour at a strange and unnatural distance from the shoulder. The veins were swelled, like these of a horse's belly ; large fungous tumours, as big as oranges, projected in a group from the outside of the arm at the place where, about two montlis before, a large abscess had burst ; and such was the foetor of the matter running from under these fungi and the languor of this poor emaciated creature, that I had no thought for the present but how to get him conveyed alive to town. After a few days, when he was somewhat recovered from the fatigues of the voyage, I proceeded to write down the history, and examine the actual state of this tumour. I found it througli- out solid, consisting chiefly of bone, little cartilaginous, hardly in any part elastic or yielding, and discharging matter, not from any superficial abscess, but apparently from the centre of this enormous mass. I had every reason to believe that the bone and the joint, which certainly were neither broken nor dislocated, had been generally injured, not merely by the shock but by the bruise ; that the parts nearest the bone, and connected with it by the periosteum, had been bruised and inflamed ; that the extreme pain for the first twenty-four hours indicated only the violence of the immediate injury, but the slow vascular action which succeeded at the distance of a month pi'oved how deeply the circulation of the bone was afi"ected, and caused that osseous secretion which generated this prodigious shell of bone, while the shaft of the shoulder-bone, from the periosteum of which this callus had been secreted, was in part destroyed by an ulcerating process within. That the ulceration, deep- seated, not only in the bone but in the joint, occasioned those excruciat- ing tortures which were announced by wild and desperate cries night and day ; that the matter, bursting at last through every obstacle, had made its Sarcomatous Cartilaginous Tumours. 349 way through that ulcerated part of the surface which is studded with the fungous excrescences represented in the drawing. "This bursting out of the matter brought relief from the pain, and he now lay in a state of extreme languor, moaning and slumbering. You found it painful even to question him, he was so feeble ; he fell, after a few broken answers, into a slumber of mere debility, and closed his eyes as exhausted ; and while I took the sketch of his posture, and of the proportions of this prodigious tumour, he slumbered continually. His extreme weakness precluded every practical experiment, and left for our discussion the speculative question only : ' In a case so deplorable and hopeless, what should we have done at an earlier stage, when the patient's strength was more entire, and youth and vigour (for he was but 21 years of age) on his side 1 ' "Here, for the first time, I felt that a bony tumour might, by advancing to the trunk of the body, preclude amputation as entirely as aneurism of the subclavian artery ! That the question here to be resolved was not whether we might dare to amputate at the shoulder- joint — the question was of amputating the scapula also, and along with it a tumour exceeding in size even the trunk of the body ! and the accident mentioned by Cheselden (an accident which has often happened since) of Wood, the miller, whose arm, scapula and all, was rudely and suddenly torn from his body, could not but come into our recollection. There was hardly left us even a choice to exercise our discretion and skill upon ; for, from the state of the veins — large, tortuous, and already ulcerating, and so numerous as to give a livid colour to almost all the surface of the tumour^t was plain that he was in daily peril of haemorrhage, and that this was at no remote period, certainly within a few weeks, to put a period to his life ! Could there then be a question whether to wait in fear of that haemorrhage which was assuredly to end in death ; or to risk by operating that htemorrhage by which he might be saved alive ? For my part, I had not the shadow of a doubt. What should determine us in any deplorable case to do desperate things ?j Surely the possibility of safety through operation, the certainty of death. I saw it possible, by tying first the subclavian artery, the root of all the circumflex arteries of the shoulder and scapula, to prevent any alarming degree of haemor- rhage ; by sawing across the outer end of the clavicle to get command of the scapula, and turn it back, as easily as the flap from an ordinary stump ; to tie, when it was cut, the arteria transversalis humeri, and certainly to separate the whole without immediate death. But had this been an enterprise as certainly fatal as the Ciiesarian section itself, still it gave some chance for life. Confident in the justness of this reasoning, moral and physical, I should have urged him to this 'awful trial, and devoted myself to the task ; but he was sunk too low for any trial, and to be regarded only as an object of charitable care. He died in the Royal Infirmary of haemorrhage, about three weeks after his admission, and these are the notes of the dissection. ^'Dissection — July 13th, 1S06. ^Having divided the integuments, 350 Diseases of Bone. whicli were extremely thin, we found, on attempting to cleanse the tumour from one extremity to the other, that it was of a substance much resembling callus ; in many places it was so firm and solid that after trying in vain to divide it with a strong knife, we were obliged to betake ourselves to the common amputation saw. "The cells of this bony tumour were everywhere filled with a matter resembling thick cheese ; the tumour itself, from its great size, and the entire appearance of the os humeri, seemed only to be attached to that bone ; but upon a more minute examination was plainly a produc- tion from its substance. The shoulder-bone could be traced through the whole tumour ; but enlarged, spongy, and ulcerated. The upper part of the scapula, the acromion process, and the outer end of the clavicle could, during life, be plainly distinguished to be enlarged, and to form part of the tumour ; and upon dissection, all the bones forming the shoulder- joint were found to be deeply diseased. The upper and most bulky part of the tumour seemed to proceed as much from these as from the os humeri, and the joint was completely anchylosed." This portion of the tumour is evidently cartilaginous. The nodules in most places are distinct, but over extensive areas they have been softened and broken down. Calcareous deposits are scattered throughout the substance. John Bell's description of the tumour does not correspond exactly to that of a cartilaginous tumour, when he speaks of matter " resembling thick cheese," unless he means " of the consistence of thick cheese." The reference, however, in the Catalogue description of this specimen to the above case could be to no other than that quoted. The clinical history as to pain and rapid growth is also strikingly like Dr Watson's case of chondro- sarcoma. (See ^0. 6. 367.) , G. C. 1270. Presented by Professor John Thomson. 6. 371. Chondro-Sarcoma of Humerus. — Photograph of the illustration of the above case in John Bell's " Principles of Surgery," vol. iii. part i., to illustrate the relative size of the tumour, and the appearance of the patient during life. G. C. 3586. 6. 372. Chondro-Sarcoma (?) of Humerus.— Plaster cast — coated with wax — of left upper extremity, showing growth of Osseous Tumours. 351 an enormous fungating tumour of the upper part of the humerus. Although this is described in the Bell Catalogue merely as the cast of a fungus tumour of the humerus, it has probably been taken from the previous case. It resembles the drawing by John Bell very closely, and corresponds to his description. B. C. I. 6. M. 3. B. Osseous and Connective- Tissue Tuviours — ranging from the slowly -growing simple forms ivhose tissties are well devel- oped, to the 7'apidly-growmg malignant forms whose tissues are more or less emhryonic. (a.) From the Periosteum and Bone. 6. 373. Ossification of Muscles of the Thig-h ("Myositis Ossificans"). — Upper end of a right femur and adjacent portion of pelvis — macerated, illustrating the above. From the margin of the obdurator membrane a sharp spicule of bone, one and a half inches in length, points directly to the insertion of the obturator externus muscle, and has evidently developed the ossification of some of its fibres. Below it, attached to the ascending ramus of the ischium, is a large irregular mass of bone which must have occupied the position of part of the obturator externus and adductor magnus muscles. The outer side of the tuber ischii is nodular. The spine of the ischium is irregular and jagged. The remaining portions of the ischium and as much of the ilium as is present are rough on the surface. On the back of the upper end of the femur there is a mass of rough spongy bone corresponding to the position of the quad- ratus femoris muscle; and below the small trochanter an irregular mass of similarly spongy bone arises from the inner surface of the shaft, and occupies a space from above downwards of about four inches, representing, apparently, ossification in the vastus internus and adjacent adductor muscles. This mass of bone is perforated by large sinuses, apparently the position of blood- 352 Diseases of Bone. vessels. It may be noted that the position of the tendinous attachments about the great trochanter shows little or no tendency to ossification, and, while the new masses of bone seem to have run into the substance of some of the muscles, other muscles in the neighbourhood — for instance, the iliacus — seem to have escaped entirely. The whole bone is very heavy. G. C. 3414. Presented by T. M. Burn Murdoch, M.D. 6. 374. Ossification in Adductor Magnus Muscle ("Myositis Ossificans"). — Plaster cast of a left femur in the Barclay Collection, illustrating the above. Attached to the femur there is a large mass, corresponding to the position of the adductor magnus muscle. The new bone Avas cancellous in texture. G. C. 3292. 6. 375. Ossification in Vastus Internus Muscle ("Myositis Ossificans"). — Right femur, lower end injured — macerated, illustrating the above. About the middle of the inner and anterior surface of the shaft there is a projecting piece of bone, which has apparently been an ossification in the vastus internus muscle. G. C. 1868. Presented by J. A. Robertson, F.R.C.S.E., 1837. 6.376. Ossification in Crureus Muscle ("Myositis Ossificans "). — Left femur, lower end missing — macerated, illustrating the above. A piece of bone projects from the anterior and outer surface of the bone, about the middle, and has apparently been an ossification in the crureus muscle. G. C. 1869. See also diseases of muscle, series 9. Presented by J. A. Robertson, F.R.C.S.E., 1837. Osseous Tumours. 353 6. 377. Distortion of Bones by Multiple Exostosis.— Femur, tibia, and fibula of a right leg ; with part of femur, tibia, and fibula of the opposite side — macerated, illustrating the above. The articular ends of the shafts are greatly distorted by exostoses, and the bones of the legs are fused. On the right side the femur has large irregular exostoses, projecting all round the neck, especially behind and below, where they have obliterated the small trochanter. The great trochanter is not much changed, but below it a large irregular mass of bone projects outwards, and while gradually tailing off into the linea aspera below, runs into the mass at the lesser trochanter in front. These masses of bone are composed of cancellated tissue, with more or less enlarged spaces. The articular surface of the head is rough and nodular below the impression for the ligamentum teres, and the hip-joint has ap- parently been anchylosed. The lower end shows numerous- projecting spines and ridges, which are largest on the outside. They do not follow the direction of any muscular fibres, and the tip in most cases is exposed, probably from having been covered with cartilage in the recent state. The tibia show& at the inner and posterior parts of the head numerous knobby and sp)inous projections similar to those on the lower end of the femur. A bridge of bone unites the tibia with the fibula about an inch below the level of the tubercle. The lower end of the tibia shows several projecting spines and knobs, and is fused with the lower end of the fibula. The shaft of the tibia shows scarcely any change. There is no ossification in the interosseous membrane, except one small spine on the tibia. The fibula is wanting at its upper end, where it should have articulated with the tibia, but below that place it is fused with it. Except at one or two spots at either extremity, where there are spinous projections, the shaft of the fibula is normal. On the left side the lower end of the femur has irregular spinous projections similar to those on the right side. The tibia and fibula are affected similarly, but more extensively than those of the right side. The upper end of the tibia is 354 Diseases of Bone. bent towards the fibula, and is fused with it at a place corre- sponding to the fusion on the right side. The connecting bridge of bone is thrown out into numerous large irregular processes, the tips of which are deficient, as if they had been covered by cartilage when recent. At one spot, on the outer side, what seems to be the remains of an articulation between the tibia and fibula is perceptible. The rest of the upper end of the tibia is little altered, except at the posterior and inner sides, where the same spinous processes are seen. The lower ends of both bones are fused into one common mass, and the bone seems to have been broadened out. A few spinous projections are seen at the lower end of both bones. As on the other side, ossification has not occurred in the interosseous membrane. (For an account of this condition, see "Arch, fiir Klin. Chir.," Band 41, p. 420.) B. C. i. 6. M. 20 to 23. 6. 378. Exostosis of the Tibia and Fibula.— Upper end of a right tibia and fibula — macerated, illustrating the above. There is an anchylosis of the two bones a little below their usual place of joining, which is very like the condition found in the previous specimens. It may be considered to be due to a bony outgrowth from each bone towards the other. B. C. II. M. 34. 6. 379. Exostosis of Clavicle. — Left clavicle of an adult — macerated, illustrating the above. The bone is stunted in growth. A large irregular mass projecting downwards from the outer end is continuous with the articular surface, which is thus much enlarged. Some irregular nodules project downwards from near the inner end, and seem in the recent state to have been capped with cartilage. The normal curves of the bone have been straightened. B. C. I. 6. IsL 16. Osseous Tumours. 355 6. 380. Exostoses of the Scapula. — Right scapula — macerated, illustrating the above. The main projection is from the sub-scapular fossa ; others arise from the inf ra-spinatus fossa and at the superior angle. They are like ossifications in the corresponding muscles. B. C. I. 6. M. 16. 6. 381. Exostoses of Humerus, — Right humerus — macerated, illustrating the above. A long irregular piece of bone projects forwards in the position of the bicipital groove, which it has replaced. Another irregular piece projects inwards about three inches below the head, and several smaller projections are seen on the back of the bone just below the surgical neck. The deltoid impression is also somewhat prominent. The head of the bone and the tuberosities are small and ill-formed, and the muscular impressions are comparatively faint. The articular surface has lost its smoothness. This appearance of the head and tuber- osities makes it probable that the shoulder-joint had been disused for many years. The lower end of the bone seems normal. This bone may have belonged to the same patient as the previous scapula, but there is no history to that effect. B, C. I. 6. M. 17. 6. 382. Exostosis of Humerus. — Left humerus — macerated, illustrating the above. A large and somewhat nodular mass of bone projects back- wards and outwards from the upper half of the shaft. This long outgrowth is for the most part in the position of the outer head of the triceps, or between that and the deltoid. The muscular impressions on the upper end are fairly well marked. B. C. I. 6. M. 19. 356 Diseases of Bone. 6, 383. Exostosis of Humerus. — Left humerus — macerated^ illustrating the above. Opposite the attachment of the deltoid a projection of bone rises from the inner side, somewhat abruptly below, but more' gradually above, when it passes into the line of the neck. The- whole bone is curved inwards. The muscular impressions on the tuberosities are faint, and the articular surface of the head is slightly roughened, as if the shoulder-joint had been anchy- losed. G. C. 3416. Presented by Macdonald Bkown, F.R.C.S.E. 6. 384. Exostosis of Ulna and Anchylosis to Radius,. which is distorted. — Eight radius and ulna of "a Dutch dwarf " — macerated, illustrating the above. The lower end of the ulna has been greatly expanded and has- become fused with the radius. A section of the expanded part shows that it is occupied by numerous irregular partitions. The outer surface is nodular and irregular, resembling the upper' end of the femur in specimen 6. 377. The shaft of the radius is flattened laterally and curved forwards, and itslower end is fused with the expanded part of the ulna. The lower articular surface of the radius looks obliquely baclcAvards and inwards. At the upper end of both bones the bony ridges are exaggerated, and the insertions of the brachialis anticus and biceps are unusually prominent. These changes were formerly ascribed to rickets, but the condition seems more allied to those of irregular exostosis seen in some of the previous specimens. B. C. i. 6. M. 18. 6. 385. Mixed Tumour of Bone. — Three sections of a small tumour (one macerated) — in spirit, illustrating the above. It was attached by a narrow pedicle to the clavicle of an adult. It is composed of cancellous bone (resembling that of the previous tumour), loose cartilage, and fat. G. C. 3361. Presented by A. G. Miller, F.R.C.S. Osseous Tumours. 357 6. 386. Exostosis of Femur. — Section of the lower end of a left femur — macerated, illustrating the above. An exostosis of cancellous tissue arises from the front of the shaft near its lower end. G. C. 3417. 6, 387. Exostosis of Rib. — Rib, said to be the sixth — macerated, illustrating the above. A large nodular exostosis projects downwards from the lower border, near the sternal end of the shaft. B.C. I. 6. M. 15. 6. 388. Exostosis of Rib, probably inflammatory.— Portions of two ribs, macerated — illustrating the above. From the body of Catherine F., who died in 1832, aged 70. Between 30 and 40 years before death, Iier left breast had been removed by the late John Bell, in the Royal Infirmary, Edinburgh, and subsequently part of a rib had also been excised. Most probably, therefore, the bar of bone between the two ribs has been the result of previous irritation, and thus is not a true exostosis. The bar was jointed to the upper of the two ribs by a ligament and joint, G. C. 1298. Presented by Dr Coldstream. 6. 389. Exostosis below Great Toe-Nail.— Section of a distal phalanx — in spirit, illustrating the above. From a girl aged 16. This is a common form of exostosis ; it lifts up the nail, and causes irritation, often mistaken for "ingrowing toe-nail." G. C. 2122. Presented hy Benjamin Bell, F.R.C.S.E., 1840. 6. 390. Exostosis below Great Toe-Nail.— Other half of the same exostosis — macerated, illustrating the above. G. C. 2123. Presented hy Benjamin Bell, F.R.C.S.E., 1840. 358 Diseases of Bone. 6.391. Ivory Exostosis of Nasal Cavity.— Section of an. irregular mass of exceedingly dense bone, from the right nasal cavity of a man aged about 40. For many years the patient had suffered from inconvenience and discharge from his right nostrih Some polypi had been removed, and about a year before this mass was taken away it had been recognised as probably a rinolith. After one or two unsuccessful attempts to remove it while the patient was under chloroform, this mass was finally extracted, but not until the anterior nares had been freely exposed, and their margins- enlarged with gouge forceps. During this operation an attempt was- made to divide this mass, and the marks of the saw are shown in the specimen. Had the saw-cut been completed, the removal would have been easier. The patient died of septic meningitis about a week after the operation, and at the ^ws^j«orfe//t examination it was found that the mass- had pressed through the cribriform plate of the ethmoid bone, and had entered the cranial cavity. On this account the operation had the more- easily set up the fatal meningitis. The section shows the dense ivory-like character of the growth. On microscopic examination it was found to be com- posed of very dense bone. It had no doubt originally grown from the ethmoid, but it must have afterwards necrosed, for it was quite loose within its cavity at the time of the operation. G. C. 3273. Presented by A. G. Miller, F.R.C.S.E. 6. 392. Ivory Exostosis of Nasal Cavity.— Plaster cast of the previous specimen before it was sawn up. G. C. 3274. 6. 393. Very large Fibro-Osseous Tumour of the Lower End of Femur.— Section of the lower half of a femur* with the above tumour growing from it — in spirit. The patient, a woman, aged 33, was admitted to Professor Chiene's ward in October 1890. Five or six years before admission, she thinks she sustained a sprain of the knee, and ever since then the knee has been swollen, getting gradually larger, but never painful. The patient has never been laid up, and only had difficulty in walking for the first time two months before Fibro-Osscous Tumour. 359 admission. About that time one lump appeared in the popliteal space, and another over the inner tuberosity of the tibia. These two have grown rapidly, but painlessly, the one over the femur the more slowly. On admission the patient had no pain in the swellings, and could walk with the aid of a stick. She had some numbness and pain in the toes an foot, and the leg was rather cold. The right knee measured twenty- three inches in circumference at the popliteal space. There were thre special swellings — the largest and uppermost, surrounding the lower third of the femur, seemed to grow from the epiphyseal line. The middle one filled up the popliteal space, and the lowest was on the anterior and inner aspect of the leg. These swellings were smooth and rounded ; the skin was drawn tightly round them, but not involved. After removal by amputation, on 15tli October, the tumour was sawn up, and found to be capsulated, smooth, and lobulated. The lower tumour had a watered silk appear- ance, like the section of a fibrous tumour. Two separate nodules of tumour substance were found in the gastro-cnemius, and both contained bone. The main mass was found fused with the femur, and was fibrous externally and osseous inter- nally. The popliteal portion was cartilaginous, and showed a transition between fibrous tissue and cartilage. The tumour was considered an " osteo-chondro-fibroma," as it was composed chiefly of bone, fibrous tissue, and a little cartilage. The specimen on one side has been stained with logwood, which shows the difference between the osseous and the fibrous parts. The cancellated tissue at the lower end of the femur is replaced by condensed bone, like that in the substance of the femur, but the outline of the shaft is still at places perceptible. Some of the new bone forming the tumour is extremely hard and dense. G. C. 3378. Presented by Professor John Cuiene. 6. 394. Fibro-Osseous Tumour of Lower End of Femur.— Portion of same tumour — macerated, to show its bony structure. The section shows the bone to be somewhat porous after the removal of the fibrous tissue. In many places it is composed of plates lying at varying distances from one another, but seldom showing the usual characteristics of cancellated tissue. 360 Diseases of Bone. The outer surface of the bone is rough, in most places owing to the intervals between the plates of bone, but at others, from needle-like radiating processes, resembling those seen in an ossifying sarcoma. G. C. 3379, Presented by Professor John Chiene. 6. 395. Fibro-Osseous Tumoup of Lower End of Femur. — Portions of bone from the previous specimen, which were developed in the fibrous tissue, but separate from the main mass. Their characteristics are similar. The tumour illustrated by this and the two preceding specimens may be classed as simple in the slowness of its growth and high development of most of its tissue, including a large proportion of bone, but as " malignant " in the steady increase of its size, in having disconnected centres of ossification, as well as in the arrangement of its bony plates. It should be stated also that while most of the fibrous tissue which formed it was fully developed, there were more rapidly growing parts which were softer in consistence and more embryonic in character. G. C. 3379. a. Presented by Professor John Chiene. 6. 396. Exostosis of Fibula.— Plaster cast of the left foot and ankle of a girl, aged nine, illustrating the above. She was admitted to the Ro3-al Infirmary, Edinburgh, on 5th August 1859, under the care of Dr. Gillespie. The tumour had grown for four years, " gradually encroach- ing on the tibia and towards the ankle." " The exostosis was broadest at its attachment to the bone. It had caused the absorption for a considerable portion of the anterior and outer portion of the tibia." G. C. 2673. Presented by 3 . D. Gillespie, F.R.C.S.E. Osteo-Sarcoviata. 361 6.397. Exostosis of the Fibula. — Plaster cast of the same foot after removal of the tumour. There is thickenmg all round the ankle. G. C. 2674. Presented by J. D. Gillespie, F.R.C.S.E. Osteo-Sarcomata, i.e. Tumours firobably similar to the previous ones, but more ra])i()ly growing. 6. 398. Slow-grrowing" Osteo-Sarcoma of the Tibia.— Upper end of the right tiLia of a young person — macerated, illustrat- ing the above. A very large osseous tumour has grown from the upper end of the bone. The only recognisable part of the shaft at the upper end is a small portion on the posterior surface. The surface is thrown out into numerous irregular processes, of a somewhat friable bone, directed outwards from the shaft. From the amount of bone formed this tumour has prob. ably been of comparatively slow growth. B. C. i. 6. M. 1. 6. 399. Slow-growing Osteo-Sarcoma of the Tibia.— Wax model representing the previous specimen when fresh. One side shows the aj^pearance of the tumour when the skin was dissected off; the other shows the appearance of the bone when newly macerated. B. C. i. 6. M. 2. 6. 400. Osteo-Sarcoma of Skull. — Greater part of the vault of a skull — macerated, illustrating the above. A churchyard prepai'ation from the north of Scotland. "The patient was a herd-girl, aged 26. About eight years before her death she exhibited symptoms of dementia, which gradually advanced to a maniacal state. She suflered from fearful headaches. A growth appeared on the side of her head, on the right parietal bone, and gradually increased in size. Suppuration took place in it, and opened externally." The whole top of the skull is covered with — in fact, is converted into — a very extensive growth of new bone in the 362 Diseases of Bone. form of plates and processes, projecting outwards from the surface. At places the skull has been penetrated. A limited amount of the new bone formation is seen in the interior, G. C. 2705. Presented by Dr Johnston, of Jamaica. 6.401. Osteo-Sarcoma of Skull.— Portion of a skull, greatly altered by the growth of the above. From a subject in the Dissecting- Rooms. "A tumour was found fixed in this part of the cranium." The original texture of the skull is replaced by a series of long plates and tubes projecting on both aspects. W. C. G. 38. 6. 402. Osteo-Sarcoma of Femur and Knee-joint.— Section of the lower end of a femur, epiphyses wanting — macerated^ illustrating the above. A mass of irregular bone surrounds the lower end of the bone, and the section shows much condensation of the interior. The friable nature of the new bone, its irregularity, and its being composed of numerous minute spicules shooting out- wards from the surface, are the characters for which this tumour has been placed among osteo-sarcomata, but it has been placed early in the series, from the comparatively large amount of bone formed. G. C. 3418. 6. 403. Osteo-Sarcoma of Femur and Knee-joint.— Sec- tion of the lower end of a femur — macerated, illustrating the above. The specimen shows a mass of irregular bone growing from the surface, with condensation of the interior. At the upper part new periosteal bone can be seen in parallel ridges, different in character from that seen on the Osteo- Sarcomata. 363 surface of the tumovir. This upper growth is beyond the tumour, and is almost certainly due to the irritation of its presence. It closely resembles the growth due to pus-forming organisms, and may be considered as "irritative." It may be seen near most specimens of periosteal sarcoma. This specimen is essentially similar to the last, except that there is less bone. W. C. G. 32. 6. 404. Osteo-Sarcoma of Femur and Knee-joint.— Lower end of a left femur — macerated, illustrating the above. There is an extensive formation of new bone round the lower end down to the articular surface, and filling up the inter- condyloid notch. The bone is composed of delicate plates and processes, extending outwards from the surface of the shaft, and more or less closely packed together at different places. Above the new growth for some distance the surface of the bone is rarefied, and beyond that there is the crust of new periosteal bone noted in the previous specimen. G. C. 320. Presented by Dr Stenhouse and Professor W. R. Turner. 6. 405. Cystic Osteo-Sarcoma of Femur. — Sections of the anterior part of the lower end of a right femur — macerated, illustrating the above. ^ The tumour occupied the whole of the thigh from the knee to the hip-joint, and was cystic in places. This specimen shows the characteristic development of delicate plates of bone running outwards from the surface with various degrees of obliquity. The disease does not seem to have reached the synovial cavity of the knee-joint. G. C. 314. b. Presented by George Bell, F.R.C.S.E. 364 Diseases of Bone 6. 406. Cystic Osteo-Sarcoma of Femur. — Portion of the shaft of the same femur as the last — macerated, illustrating the above. There is a remarkable development of delicate osseous plates growing from the shaft. These plates are themselves composed of finer processes and plates of bone. The open nature of the larger plates may be associated with the cystic character of the tumour. G. C. 314. a., 321. Fresented hy George Bell, F.R.C.S.E. 6. 407. Cystic Osteo-Sarcoma of Femur. — Portion of the soft part of the tumour from the previous case — in spirit. It appears to be composed of a soft, fibrous material containing numerous cysts. G. C. 314. c. 6. 408. Osteo-Sarcoma of Fibula. — Left fibula of a young person — macerated, illustrating the above. Surrounding its upper end there is a mass of new bone, delicate in structure, and composed of numerous fine plates and spicules. Some of these run horizontally outwards, while others pass vertically, parallel with the long axis of the bone. B. C. I. 6. M. 10. 6. 409. Osteo-Sarcoma of the Lower End of the Femur. — Section of the lower end of a right femur — in spirit, illus- trating the above. The patient was an athletic and powerful man, about 35 years of age. For some months before amputation was performed, he had felt obscure pains about the knee. These were thought to be due to varicose veins. Afterwards a swelling appeared, and even then the condition was obscure. He was seen by several leading surgeons, and the diagnosis of sarcoma was at length arrived at. Amputation below the trochanter Ostco-Sarcomata. 365 was performed by Dr John Duncan, nearly a year after the symptoms first began. The patient made an excellent recovery, and had returned to business, when the disease appeared in the brain, and, after a few weeks' illness, carried him off. The section shows the tumour to be growing round the outside of the bone, which is, however, also partly affected in the interior. The substance of the tumour is vascular, soft, and friable, with a few bony spicules. Under the microscope it is a large spindle-celled sarcoma. G. C. 3463. Presented hy Alexis Thomsox, F.E.C.S.E. 6.410. Osteo - Sarcoma of the Lower End of Femur.— Anterior half of the lower end of a right femur — macerated, illustrating the above. A somewhat lobulated tumour has grown from the inner side at and above the knee-joint, and apparently contains bony spicules. In the interior the tumour substance has invaded the cancellous tissue. G. C. 2478. 6. 411. Osteo-Sarcoma of Leg" and Foot.— Section of the lower part of a right leg and foot — in spirit, illustrating the above. "1828. — Mr B., aged 57, healthy and active, formerly of habits unmarked by any peculiarity, about eight years ago, while travelling by night on the outside of a stage-coach, had his legs and feet extremely lienumbed with cold, and in a few days they were affected with severe pain. The left leg soon grew permanently well ; the right leg never did. The pain was seated in the shin-bone, varying according to the season and state of the weather. About two years since, the anterior angle of the tibia had become serrated {sic); in a few months afterwards a swelling of the perios- teum appeared on the middle of the bone. This was reduced by a blister and issue. In February 1827 the lower two-thirds of the bone were become enlarged. Numerous processes from the anterior and posterior angles distended the neighbouring muscles ; much thickening of the soft parts round the lower end of the bone, and cedema of the foot. At the end of three months, during which the treatment consisted of repeated applications of leeches and blisters, mercurial alteratives, sarsaparilla, and regulated diet, there was a considerable diminution of the pain and of the swelling of the soft parts, but little or no reduction of the size of the 366 Diseases of Bone. bone. Amputation was now advised, but Mr B. was induced to place himself in the hands of a quack, who applied stimulating plasters to the leg, with a view, he said, of bringing on suppuration, and salivated Mr B. with mercury. At the end of three months this person was dismissed, and the former medical attendant again requested to see the patient. A great change had taken place — emaciation, pale complexion, bad appetite, constipation of the bowels, a quick, weak, and irregular pulse ; the leg greatly increased in bulk and deformity, hard all over, and exquisitely painful. Its surface was irregular in consequence of several large tubercles, round, firm, and elastic, and somewhat yielding to pressure. The colour of the leg is livid and dark purple, and the tubercles of a dusky yellow, some of them superficially excoriated. The tibia, up to its tubercle, is swelled. The knee and thigh are apparently sound, but the inguinal glands are enlarged and indurated, thougli not painful. In a consultation with Professor Russell and Dr Thomson, amputa- tion was again judged proper. This was performed, above the knee, on the 4th September last (1827). The leg was injected with minute-size injection, and a vertical section made. The tibia nearly in its whole length appeared enlarged, and degenerated into a texture more like the carcinomatous than any other. The tibia at its middle seemed a little bent, as if it had yielded to the weight of the body. All the soft parts, with slight exceptions, had the same marked appearance as the tibia. Tlie stump healed in good time. The swelling of the inguinal glands entirely subsided, and the patient, with occasional slight attacks of indisposition, recovered his former health and vigour, A slight irregularity of the pulse remains, which, previous to the removal of the limb, was conjectured to depend on a thickened state of the cardiac valve, and was considered as no objection to the operation. The tumour, which is blanched by the spirit, has sur- rounded the tibia, and in its growth outwards has apparently partly infiltrated the muscles, partly pushed them and the tendons before it. G. C. 1035. 6.412. Osteo-Sarcoma of the Tibia. — Transverse section of the tibia and tumour from previous case — in spirit, illustrating the above. This section of the tumour shows its relations and mode of OTOwth even better than the last one does. G. C. 1035. a. 6. 413. Osteo-Sarcoma of the Tibia.— Macerated portion Osteo-Sarcomata. 367 of a transverse section of the tibia from, the previous case, to illustrate the above. An irregular outgrowth of bone surrounds the tibia, and has evidently been part of the tumour. G. C. 1035. 6.414. Osteo-Sarcoma of the Tibia.— Plaster cast of the leg and foot from the previous case, before amputation. The cast shows well the characters described in the history of the case 6. 411. G. C. 1036. 6. 415. Osteo-SaPCOma of Tibia.— Upper parts of a tibia and fibula of a young person (epiphysis not yet united) — macerated, illustrating the above. There has been considerable loss of substance of the tibia at one place with development of new bone in the form of delicate spicules and plates at other places near. This has probably been a case of rapidly growing periosteal sarcoma? which has worked inwards as well as outwards. G. C. 376. 6.416. Osteo-Sarcoma of Innominate Bone.— Portion of an innominate bone — macerated, illustrating the above. A very large fungus tumour enveloped this bone. The ouCer surface is covered with beautifully delicate spicules and plates, running outwards in various degrees of obliquity, the original bone below being greatly opened out. A cast of the os innominatum, shoAving the tumour, and also a specimen of the tumour, were entered in the General Catalogue, but cannot now be traced (1893). G. C. 815. 6.417. Osteo-Sarcoma of Humerus.— Section of j;he lower 368 Diseases of Bone. end of a humerus and elbow-joint, with tumour and adjacent soft parts attached — injected with carmine and gelatine, and in spirit, illustrating the above. The patient was a man, aged 68. The swelling appeared at the back of the arm one year before the operation, and was taken at first for an enlargement of the bursa over the olecranon. The rapid growth, however, soon made its nature apparent, and the arm was amputated. The tumour was soft, with small calcareous and osseous deposits scattered throughout it, especially at the margins. It has invaded the bone, and seems to have pushed the muscles and fascia aside rather than infiltrated them. G. C. 2837. Presented by Joseph Bell, F.R.C.S.E. Periosteal-Sarcomata, i.e., Tumours like the preceding, only growing too rapidly for much development of bone. 6. 418. Periosteal Sarcoma of Femur. — Posterior half of a left femur, with a periosteal sarcoma growing from its middle two-thirds — in spirit. "John Wright, aged 13, was admitted into the Royal Infirmary under Dr Handyside on 13th June 1843, with an extensive tumour of the left thigh-bone. "Six years since he had an attack of scarlatina, on recovering from which the left thigh remained weaker than the other, and appeared also to be smaller in size. For this the part had been rubbed frequently with various ointments. He continued to go about, otherwise quite well, till about six montlis ago, when, during the night, he was suddenly seized with violent pain in the thigh. Poultices were next applied to the affected part, and afterwai-ds sinapisms and a few leeches ; but under the treatment the thigh increased rapidly in size. Since then the tumour has gradually increased, and of late he has experienced considerable uneasiness from the frequent pain in it, and the deprivation of sleep thus occasioned. "On examination, the thigh was found to be much enlarged, especially at its middle, whence it tapered gradually towards each extremity. The tumour was hard and inelastic, connected evidently with the OS femoris, and it occupied about the three middle fifths of that bone, leaving its extremities of nearly the normal size. Its surface was smooth and regular, and over it the muscles and other soft parts could be moved freely. The integument over the disease presented a somewhat glistening appearance, but was not discoloured ; and beneath it there appeared some faint blue lines, indicating distension of the superficial veins. The tumour was the seat of acute, darting pain, which became Periosteal Sarcomata. 369 increased towards night, and also underwent occasionally severe exacer- bations. "The lymphatic glands of the groin and of the rest of the body were carefully examined, and found not to be enlarged or otherwise affected. The motions of the hip-joint were perfect, and were performed without giving rise to pain. The limb below the knee was much emaciated. The countenance of the patient was sallow, and had an emaciated appearance, and his tongue was of a bright red colour. His body generally was not much emaciated, and his health appeared on the whole to be good." [The London and Edinburgh Monthly Journal of Medical Science. — Eeport of Case by .John Struthers, Esq., House Surgeon, Royal Infirmary, vol. v., 1845.) On 13th June the thigh was amputated at the hip-joint by Dr Handyside by the transfixion method, and the patient made a good recovery ; and six weeks after the operation, i.e. 5th August, he left the Royal Infirmary, with the ligatures still discharging, but the stump other- wise doing well. Soon afterwards he complained of occasional frontal headache, fol- lowed by pain in the left orbit and eyeball, with increased sensibility to light and lachrymation. About the middle of August a small chronic abscess formed over the occiput. These pains subsided for a time, but by the end of September had returned with such severity as to confine him to the house. By the end of October Dr Handyside drew up the following report : — " The left eyeball was very prominent and discoloured ; almost complete loss of vision. The eyelids were so much tumefied as almost to conceal the eyeballs, and the veins of the eyelids were very conspicuous, being enlarged and tortuous. The orbit itself appeared to be also enlarged and prominent, especially towards its upper and outer part, forming there a hard, inelastic swelling. These parts were the seat of continual stinging, pain, which prevented sleep, and was fast undermining his strength. Three chronic abscesses were situated over various parts of the head. There was a tumour of the size of an egg on the left hypochondrium, which was firmly adherent to and connected with the cartilages of the upper false ribs. It was slightly elastic to the feel, had grown rapidly, and was the seat of acute darting pains, being, like the tumour of the orbit, decidedly of a malignant character. The disease seemed to be fairly begun in the stump, particularly in that part of it which had been irritated by the long retention of the ligatures, as, at the part where the last ligature had lain, a small pale-coloured fungus protruded. The patient's body generally was emaciated, and his strength was worn down by the continued pain and the malignant hectic. To procure sleep he had been for some time in the habit of taking frequent and full doses of the solution of the muriate of morphia." After this he rapidly sank, and died on 11th November, four and a half months after the operation. No post-mortem examination could be obtained. The tumour is lobulated on the surface, but has infiltrated 2 A 370 Diseases of Bone. the muscle, part of which is adherent to it. On the surface of i;he femur there are indications of erosion at some places, and ■of development of bone at others. The surface of section shows the femur to have been somewhat condensed in the interior, with tumour substance in the medullary cavity above the condensed part. Below it the cancelli form large spaces, and these at the time of section also contained sarcomatous material, part of which has since fallen out. The neck of the bone is partially absorbed, and the head is flattened from «bove. The whole bone was found "more soft and sectile than natural," G, C, 2273. Fresented by P. D. Handyside, F.K.C.S.E. 6. 419. Periosteal Sarcoma of Femur.— Cast in wax of the previous specimen before section. The fusiform shape and the sligMly lobulated character of the surface of the tumour are well brought out. G. C. 2274. Presented hy P. D. Hakdyside, F.KC.S.E. 6. 420. Stump after Amputation for Periosteal Sarcoma of Femur.-Plaster of Paris cast of the stump from the previous case. The cast was made on 10th September by Dr M'Lean. It shows a considerable swelling in the groin and in the anterior flap, for by that time the disease had recurred in the stump. G. C, 2275. Presented by P. D, Handyside, F.R.C.S.E. 6. 421. Periosteal Sarcoma of Femur and Knee-Joint.— Quadrant section of the lower part of a thigh — in spirit, illus- trating the above. R. W., aged 18, Was admitted to Royal Infirmary, Edinburgh, on 4th September 1888. His mother and an aunt had died of consump- tion, but his family history was otherwise good. The swelling dated from an injury in the beginning of June of the same year. At first^,there was swelling and pain at the inner side of the knee. These increased rapidly, anl in three weeks quite prevented him Periosteal Sarcomata. 371 from walking. The swelling varied in size from time to time, and the pain which increased with the swelling was greater at night. It was sometimes sharp, sometimes aching. Blistering was tried without avail. There was difficulty at first in diagnosing between tubercular disease of the knee-joint and sarcoma of the lower end of the femur. The latter, however, was finally decided upon, and on the 10th of September amputation was [)erformed at the hip-joint. Two days afterwards he died. The disease seems to have begun in the periosteum, just above the epiphyseal line, and to have spread in all directions, i.e., along the surface of the bone and into the medulla, into the soft textures of the joint, and outwards into the thigh. The disease has extended higher under the periosteum than it has in the medulla. The specimen was injected first with carmine and gelatine, and afterwards with tallow and vermilion, and the latter injection mass can be seen in numerous medium-sized arteries at the margin of the tumour, and also in many places within its substance. G. C. 2807. Presented by James Hodsdon, F.R.C.S.E. 6. 422. Periosteal Sarcoma of Femur and Knee-Joint. — Small portion of the femur from the previous specimen — macerated, to illustrate the above. The surface of the'condyle, and of the shaft of the femur for four or five inches above it, is rarefied and partly absorbed. Above that there has been a slight but distinct development of the spicular bone characteristic of ossifying sarcomata. This, as it is traced upwards, forms a porous crust, which fades gradually away, but its margin is distinguishable from the surface above which is that of ordinary periosteal irritation. G. C. 2807. b. Presented by James Hodsdon, F.E.C.S.E. 6. 423. Periosteal Sarcoma of Femur and Knee-Joint.— Glue and glycerine cast of the knee-joint in the foregoing case, before operation. The cast shows well the globular swelling of the knee- joint, which rendered the diagnosis at first so difficult. G. C. 2807. a. Presented Sy Charles W. Cathcart, F.R.C.S.E. 372 Diseases of Bone. 6. 424. Fungrating Periosteal Sarcoma of Tibia.— Sec- tion of the upper end of a left tibia, with patella, lower end of femur, and adjacent soft parts injected with vermilion^ and in spirit, illustrating the above. The following account is taken from Sir Charles Bell's "Surgical Observations of Cases in the Middlesex Hospital," etc., 1816, p. 390 : — " French "Ward (Middlesex Hospital). James Lewsley, aged 17. — I observed this young man in the waiting-room, as an Out-patient. He- said his friends alarmed him by saying that he was going to have a white swelling in his knee. I found a disease, not in his knee, but in the head of the tibia, a tumour which to the eye appeared like a swelling over the bone ; but which, on examining it more particularly, was obviously attended with an enlargement of the bone. Three months before this he- had experienced a slight pain on the inside of the knee and head of the tibia, and it has continued till the present. " From the moment I saw this patient I felt anxiety for him, and pointed out to the pupils that this was a tumour forming within the bonCy and not a scrofulous enlargement ; and desired that they should watch it, as in all probability it would prove another example of the fungus hcematodes. "For some weeks this jjatient was treated as for inflammation of a bone, by repeated application of leeches and blisters on alternate sides of the head of the bones ; for presently it appeared that the heads of both the tibia and fibula were affected. By this means the general swelling: was diminished, but on the outside, immediately below the patella, there remained a tense elastic swelling, resembling in some degree an enlarged bursa. Leeches were again applied and an issue made by caustic. But these means, added to opiates and sudorifics, had no effect in arresting the progress of the tumour, for the swelling had assumed a form which authorised that name. The opening by the principal caustic became an ulcer ; that is to say, it showed a peculiar character, and began to widen. And observing that the leg had become cedematous, and that the tumour of the bones enlarged, and the ulcer had obviously a connection with the disease of the bone, I took the lad into the house on 22nd August. "31si. — The tumour has increased in an extraordinary degree ; it is larger than the first, and quite open and full-blown, like a flower. In its substance it is spongy and soft, and easily broken down ; in colour it is cineritious, like slough, and bloody. It bleeds on being roughly treated, but has no sensibility. The young man's health begins to break. He has been informed of the change which would take place, and now it has come he stands prepared for the worst, and has consented to lose the limb. A cold lotion has been constantly on the limb, yet the tumour has increased with remarkable rapidity ; it is of the size of both fists, and embraces the heads of the tibia and fibula. The leg is osdematous and the integuments inflamed. "The limb was amputated about the 6th of September. Periosteal Sarcomata. 373 ''2Qth. — He has had a restless night ; his pulse is quick (100), and "his tongue white ; he was attacked with a rigour, which has been suc- ceeded with heat. He is very sick and cannot retain anything on his stomach, and his countenance is sunk. " Observations at evcni7ig lecture. — You have seen that I examined this patient very particularly to-day, and indeed his situation is very interesting ; you may have seen that the stump looks well, the ligatures long since removed, and the wound contracted. There does not seem, therefore, any source of irritation in the stump. Whence then arises his present condition ? He daily wastes away, and is very thin : he has shiverings followed with flushes ; his tongue is white, and he is covered with perspiration, and there is a slight yellow tinge on his skin. Such an attack will sometimes precede the ojiening and disorder of a stump about the ninth day after the operation ; or the patients in Hospital will be aff'ected by the crowded state of the house. I wish I could so consider the present attack, but I fear it is from another cause — from the irritation of internal disease." These symptoms increased, with the addition of pains in the right side, and heaviness in the stomach. The patient gradually sank and died •on the 24th. " Fost-morte7n. — The right side of the liver was much enlarged, and "the surface was like variegated marble. There were spots of a bright yellow colour, from the size of a pin's head to that of the point of the finger. These spots were in clusters, and such parts of the liver felt soft, and around these spots there was a vascular structure, deeply stained with blood. Similar spots of disease were seen on the lungs, and some of these were of a vascular, soft texture, having the peculiar substance of the soft cancer intervening." Although the tumour is stated to have begun within, it seems more probably to have begun in the periosteum. In contrast to the healthy texture of the lower end of the femur, the tibia has a condensed appearance, from its cancelli being iilled with tumour substance. This has been observed in almost all the preceding periosteal tumours, and is quite different from the destructive changes produced by a central tumour growing at an equal rate with this one. The surface of the tibia has been attacked by the tumour. Without maceration, it cannot be said what amount of new bone, if any, has been formed ; but even if there were little or none, this would still be in keeping with a periosteal tumour which had grown very rapidly. B. C. I. 6 M. 25. 374 Diseases of Bone. '"^6, 425. Osteo - SaPCOma. — Section of an osteo-sarcomatoas tiimour, in -whicli nodules of bone are interspersed among fibrous tissue ; well developed. F. P. C. 2781. 6. 426. Osteo-Sarcoma of Pubes. — Soft portions of a tumour of the pubes. The patient was treated for a long time for psoas abscess, under which complaint he was supposed to be labouring. The substance of the tumour is firm, with a few bony spicules at some parts, and softening at others. G. C. 1059. Presented by Professor James Russell. 6. 427. Osteo-Sarcoma of the Sacrum. — Plaster cast of the pelvis of a woman, aged 26 — illustrating the above. The patient was in labour for the first time. At the end of forty- eight hours she submitted to the operation of Cresarean section, but died seventeen hours afterwards. The foetus was still-born. (For case, see "Edinburgh Medical and Surgical Journal," No. 106.) The tumour had groAvn forwards into the pelvis, and quite obstructed the passage. G. C. 1476. Presented by William Campbell, F.R.C.S.E. C. Medullary or Central Tumours — ranging from the slowly- growing simple forms whose tissues are well developed {red marrow being normally cellular) to the rapidly -growing- malignant forms whose tissues are more or less embryonic. 6. 428. Slow-growing- Central Tumour of Lower End of a Femur. — Section of the lower end of a femur, with adjacent soft parts — in spirit, illustrating the above. The patient, M. G., a young woman aged 27, a dressmaker, wa& admitted to the Royal Infirmary, Edinburgh, on 8th November 18S8, suffering from a large tumour affecting her knee. * This and the next two specimens properly belong to the jtrevious group of " Osteo-Sarcomata." The oversight was not recognised until after the type was set up, when it did not seem worth while to re-arrange them. Myeloid Sarcomata. 375 She, though never very strong, had always had fair health until eight years ago, when she fell and hprt her left knee. It was sprained,, according to her doctor, and was "put in" by a bone-setter, after which she could walk. The knee remained swollen, but was not painful. She used a crutch till three years ago. In July 1888 "rheumatism" and swelling all round the knee-joint set in, and this has gradually increased until it has reached its present size. It is not painful. The tumour, which is in the neighbourhood of the knee, measures twenty-four inches and a half in circumference, and fifteen inches in length. The patient can walk, but the knee is somewhat flexed. The leg was amputated by a postero-internal flap, and the patient did well, except for occasional attacks of gastritis, to which she was previously subject. She was discharged cured on 14th January 1889. The tumour is composed partly of bone, partly of fibrous tissue, and partly of a soft substance, which has been breaking down. The bony part, consisting of both cancellous and compact tissue, forms walls and septa for the softer portions. The soft tumour substance has apparently grown through the lower end of the femur, and stretched the soft parts beyond it. Part of the cartilaginous surface of the condyle still remains apparently normal. The soft substance is composed of round and spindle cells, with numerous giant cells. This slow-growing central tumour of the lower end of the femur may be compared with the similarly slow-growing peri- osteal tumour of the same part (No. 6. 393). G. C. 2838. Presented by Professor T. Annandale. 6. 429. Myeloid-Sarcoma of the Head of the Tibia.— Fibula and section of upper end of tibia — in spirit, illustrating the above. C. W., aged 36, was admitted to "Ward 12, Royal Infirmary, Edin- burgh, in April 1890, suQ'ering from swelling over the head of the tibia. Fourteen months before he had received a blow on the leg by a falling stone, which kept him from work for a few days, and caused him pain, but no other discomfort. This was followed by a swelling, which was incised five months later, with negative results. Gradually the swelling increased in size. The patient had been losing flesh for four or five months. On admission there was a large swelling over the head of the tibia, painful on pressure, and yielding with a crackling sensatiou. Ou 376 Diseases of Bone. 4th April Mr Duncan amputated the leg at the knee-joint, and the patient made a good recovery. In most parts the marginal bone has been reduced to a mere shell. Below and near the outer tuberosity the tumour substance is invading the healthy-looking bone, but with very little infiltration. When fresh, the tumour had the characteristic appearance of a myeloid sarcoma. At one spot, i.e. below the crucial liga- ments, there was some greyish sarcomatous-looking substance, but all the rest was like blood-clot, crimson, orange, and yellow in colour, as if in varying stages of decolorisation. These appearances are now much altered by the action of the spirit. The blow had evidently broken the fibula, and seems to have splintered the tibia. G. C. 3174 Presented by John Duncan, F.R.C.S.E. 6. 430. Myeloid-Sarcoma of the Head of the Tibia.— "Water-colour drawing of the above tumour, showing its charac- ters when fresh, by K. Murray, artist. G. C. 3174. a. 6. 431. Central Sarcoma of the Upper End of Fibula. — Section of a right tibia, partially surrounded by an enormous tumour of the fibula, with the adjacent soft parts — in spirit. Mrs T. , aged 62, was admitted to Chalmers Hospital in October 1890. She had been healthy until the present tumour began, about ten years before. The first symptom was pain over the head of the right fibula. This was followed by swelling in the neighbourhood, which increased gradually at first, but rapidly for the last twelve months. On admission the tumour surrounded the leg completely in its upper two- thirds. The maximum circumference of the tumour was twenty-two inches. The skin over it was tense, and the veins were dilated. To the touch it felt mostly firm and fibrous ; it was fluctuating and apparently cystic in places, with a few calcareous masses perceptible in the walls of the cysts. Amputation was performed through the lower third of the thigh in October 1890, and the patient made a good recovery. Central Sarcomata. 377 The tumour, when fresh, appeared to the naked eye to be a sarcoma infiltrating the muscles and tissues of the leg, with large areas of degeneration and blood extravasation. Micro- scopically, it was found to be a "fibro-sarcoma." The greater part of the interior of the tumour was so soft and diffluent that it was washed out from what is now seen as an empty space. The upper end of the fibula is completely destroyed, but there are some plates of bone still remaining in the wall of the tumour. The tumour has, therefore, evidently burst through the fibula, after having partially expanded it. The muscles are stretched over the tumour, and partly involved in it. G. C. 3233. Presented by P. H. Watson, F.E.C.S.E. 6. 432. Central Sarcoma of Fibula.— Lower end of a right fibula — macerated, illustrating the above. The bone about the middle has been transformed into a hollow shell, the wall of which is in some places very thin, while at others it is half an inch thick, and is composed of cancellated tissue. The lining of the interior shows irregular cavities. This specimen was formerly described as a case of " spina ventosa." W. C. G. 28. 6. 433. Central Sarcoma of Tibia.— Part of a right femur and bones of the leg and foot of a child— macerated, illustrating the above. The lower half of the tibia has been destroyed by what must have been a central tumour. The affected part is represented merely by a membrane at the back and outer side, continuous above with the shaft. The interior of what remains of the cavity is smooth. The fibula in the region of the tumour has been flattened out into an elongated 378 Diseases of Bone. plate, and is blended with the membranous wall of the cavity. Apparently, therefore, the tumour has been of comparatively slow growth. The bones of the foot are light and translucent. B. C. I. 6. M. 4. 6. 434. Central Sarcoma of the Ulna. — Remains of the lower end of a left ulna, with corresponding part of radius and the first row of carpal bones — muscles cleaned off and in spirit, illustrating the above. The lower end of the radius has been almost completely destroyed, and an imperfect shell, composed partly of bone and partly of membrane, with "honeycomb" markings on its interior, is all that now represents it. This must have been a central tumour, which has been re- moved in the process of preparation. Formerly called "spina ventosa." G. C. 1060. Presented by Professor James Russell, 1827. 6. 435. Central Sarcoma of the Lower End of the Humerus and Elbow-Joint. — The section shows the lower end of the humerus to present a V-shaped opening towards the elbow-joint, A mass of decolorised tumour substance occupies the elbow-joint, and surrounds the head of the radius. It projects also from the skin backwards, but has been sliced off there. On the inside, the skin over the joint is scarred, probably the result of former treatment. G. C. 791. Presented by Sir George Ballingall, 1825. 6. 436. Central Sarcoma of the Lower End of the Humerus and Elbow-Joint. — Plaster cast of previous tumour before amputation. F. P. C. 2906. 6. 437. Central Sarcoma of the Lower End of the Femur. Central Sarcomata. 379 — Section of the lower end of an injected left femur and adjacent part of tibia, soft parts partially dissected — in spirit, illustrating the above. A large tumour growing from the lower end of the femur has almost entirely replaced it. The tumour is composed of lobuks of soft substance, separated by firmer and more vascular tissue, and^breaking down in the centre. The tumour has invaded the knee-joint, and has grown through the femur all round, especially behind. The bone is eroded but not expanded, and is not apparently infiltrated. A distinct capsule has been formed by the soft parts round the tumour. Described formerly as a "cancer of the lower end of the femur." G. C. 2446. Presented hy Bell Pettigkew, F.R.C.S.E. 6. 438. Central Sarcoma of the Humerus.— Right humerus, muscles dissected off — in spirit, illustrating the above. A firm mass is seen continuous with the bone, and entirely replacing it between the upper third and the condyles. Various sections have been made, and a hole has been cut through the interior. The soft parts round the tumour have been pushed aside and an appearance of a capsule has been formed. G. C. 1054. Presented hy Professor James Russell. 6. 439. Sarcomatous Tumour of a Rib.— Portions of two ribs of the left side — in spirit, illustrating the above. The interior of the lower of the two ribs is entirely re- placed by a tumour. The substance of the tumour is some- what spongy and spicular, and seems to have been breaking down. The upper of the two ribs is partly absorbed by the pressure of the tumour, which seems fairly well encapsuled on the outer and inner aspects. " The section of a tumour formed on a rib, supposed by 380 Diseases of Bone. some to be cancerous, by others to be scrofulous. I suspect the latter, as it wants those hard membranous septa so char- acteristic of schirrhus. When the fleshy parts are removed by putrefaction, the bone of this tumour puts on the same appear- ance as is seen in G. 38," i.e. 6.401. W. C. G. 43. 6. 440. Sarcoma of Rib. — Portions of the fifth, sixth, and seventh right ribs, with a small portion of lung and liver — in spirit, illustrating the above. The patient, aged 44, was a strong and healthy man, though rather addicted to alcohol. There had been no injury, so far as was known, and no instance of malignant disease in the family history. The tumour grew first on the sixth rib, and when first noticed was about the size of a small bean. He consulted Dr Craig, who became suspicious of malignancy, from the fact of the man's losing flesh rapidly, without any other apparent cause. In six months after Dr Craig was first called, the man died. At the post-mortem examination, the tumour was found to be about the size of a small orange, and projected not quite so far into the pleural cavity as outwards. It was not adherent to the pleura. Secondary deposits occurred throughout the liver, and the lungs also showed traces of being affected. (See the "Edinburgh Medical Journal," February 1885, p. 735.') The muscles lying over the primary tumour have been partly pushed aside, and there is an appearance of a capsule. This, it should be noted, is often misleading, and should not in practice be allowed to contra-indicate malignancy. G. C. 2716. Presented by y^. Ciiaig, F.R.C.S.E. 6. 441. Sarcoma of the Body of the Scapula. — Scapula and upper arm of a boy, aged ten — in spirit, illustrating the above. The tumour had been several months growing. The case was first under the care of a medical man in the north, who recognised its Central Sarcomata. 381 gravity. It, however, passed out of his hands into those of a female bone-setter, who did not improve matters by her attempt to set the so- called dislocation. The patient then returned to his first attendant, who sent him to the Infirmary, to be under Dr Joseph Bell's care. It was at once evident that nothing short of amputation of the arm, scapula, and greater part of the clavicle, would be of the slightest use. The tumour involved both supra- and sub-scapular regions, and pressed on the axilla. It was also adherent to the skin of the back. The operation was performed, and the boy made a good recovery from it, but died some months after from a return of the disease. The tumour, which seems to have grown from the scapula near the neck, has spread in all directions, and has infiltrated the adjacent muscles. G. C. 2725. Presented hj 3 osEPK Bell, F.R.C.S.E., P.R.C.S. 6. 442. Central Sarcoma of the Head of the Tibia.— Section of the upper end of a left tibia — in spirit, illustrating the above. Four months before admission to the Royal Infirmary, Edinburgh, the patient — a girl aged nineteen — had felt a pain below the left knee. A swelling appeared, which was blistered without benefit, then poulticed and incised, but only blood escaped. The pain returned nine weeks after the opening had healed. There was by this time a distinct hard lump, which gradually enlarged. On her admission to the Infirmary, on 10th September, the swelling lay midway between the tibia and fibula, about one and a half inches below the level of the head of the fibula, but apparently unconnected with either bone. The swelling was blistered and then incised, but blood only escaped, and the wound thus made rapidly fungated. Amputation above the condyles was performed by Mr. Cathcart on 19th September 1888. The patient left the Hospital apparently in good health and spirits. A few months afterwards, however, she became exceedingly peevish and fretful, and, after emaciating rapidlj-, died with symptoms of a cerebral tumour. No post-mortem examination was obtained, but a secondary deposit of the tumour had probably attacked the brain. The section shows a soft tumour invading and replacing the cancellous tissue of the head of the tibia and infiltrating the soft textures outside, G. C. 2804. Presented by Charles W. Cathcart, F.R.C.S.E. 382 Diseases of Bone. 6. 443. Central Sapcoma of the Tibia. — Portion of a tibia— in spirit, illustrating the above. An infiltrating sarcoma has invaded and replaced the interior of the bone, and has formed a fungus mass on the surface outside. G. C. 185. 6. 444. Central Sarcoma of the Tibia. — Section of a left tibia periosteum removed — in spirit, illustrating the above. A sarcoma has invaded and replaced the interior of the bone, near the upper end. G. C. 3104. Presented by Macdonald Brown, F.R.C.S.E. 6. 445. Central Larg-e Round-celled Sarcoma of the Upper End of the Femur. — Section of the upper end of a left femur, with portion of tumour and muscles attached — in spirit, illustrating the above. The patient, aged 22, a butcher, tall (six feet), and tliin, and seems to have rather overgrown himself. Still, he has been always healthy enough, though rather subject to colds. His family history is good. In this end of February 1891 patient had "sciatica-like" pains in the left thigh, chiefly in the knee, and occasionally running up to the thigh. He rubbed in a strong embrocation, and poulticed the painful places at times. On the 6th July the pain became much worse, and Dr. M. was summoned. He gave him some medicine internally, and a lini- ment for the leg, which eased the pain during severe attacks. The pain was intermittent, worse at nights, and at times very severe. It jirevented him from attending to his work. On 13th July he had improved and went back to work. The leg felt stiff, and he limped a little, but the pain was gone as long as the leg was kept quiet. But a slight jerk would cause intense pain, running down the front and inner side of the thigh. On the 13th and 14th July he continued at his work, which required him to be on his feet for nearly the whole day. On the 15th he went to work, but the pain came on in the thigh so severely that he had to go home. Dr. M. ordered rest, and he has remained in bed ever since, rarely sitting up for an hour or two at a time. The pain continued pretty severe. On 16th July a little lump appeared on the side of the thigh, about 3 inches below the great trochanter. This soon disappeared with rubbing. But at this time the pain was severe up and down the thigh and leg, sometimes into the foot, but always most severe at the knee. Central Sarcomata. 383 On the 29th July (at 11.30 a.m.) patient was lying on his back in bed, with his left leg drawn up. He was in the act of turning on his side, when he felt the thigh give a great crack in its upper third. The pain was intense, causing him to "roar out " at the time, and it remained severe for some time afterwards. On the morning before the crack, the patient had noticed a slight diffuse swelling of the thigh. After the crack the swelling quickly increased, till in three days it had reached its full size. At this time several injections of morphia were given, and the thigh was rubbed well with a liniment. The pain gradually decreased, and on 13th August he was free from pain, except when he gave the leg a jerk. On the ISth and 19th August he had slight sciatica pains in his foot. On 21st August an exploratory incision was made, and the previous diagnosis of sarcoma of bone was confirmed. On 25th August Mr Cathcart amputated at the hip-joint. The patient bore chloroform badly, and had to be stimulated several times with ether. Comparatively little blood M'as lost, and the patient did fairly well until 7.30 P.M., when he began to collapse, and died at 11 p.m. The section shows that the tumour must have begun in the centre, just below the level of the great trochanter, where the bone is destroyed. It has extended down the medulla, and upwards into the cancellous tissue, but its chief growth has been outside the bone, entirely surrounding it, and infiltrating the adjacent muscles, although at places there is an appearance of a capsule. The upper fracture must have been the spon- taneous one recorded in the history. The lower fracture was accidentally produced in sawing the specimen, but the bone was greatly weakened there by the disease. The substance of the tumour, when fresh, had a consistence and appearance like the white substance of the brain, except that at certain places it was more vascular. Microscopically, this is a large round-celled sarcoma ; formerly it would have been called an " encephaloid cancer." G- C. 3322. Presented by Charles W. Cathcart, F.R.C.S.E. 6. 446. Central Large Round-celled Sarcoma of the Upper End of the Femur. — Water-colour drawing of the above tumour when fresh, by John T. Kelly, artist. G. C. 3321. 384 Diseases of Bone. 6. 447. Central Larg-e Round-celled Sarcoma of the Upper End of the Femur. — Anterior half of the upper end of the above femur — macerated. It shows the destruction of the bone at one spot, and its rarefaction at others. There is a slight amount of new periosteal bone formed beyond the rarefied area, probably " irritative," and due to the tumour's growth. G. C. 3323. Presented hy Charles W. Cathcart, F.R.C.S.E. 6. 448. Central Large Round-celled Sarcoma of the Upper End of the Femur. — Macerated fragments of the above tumour, which fell apart when a portion Avas macerated. These show that bone was scattered in isolated pieces throughout the tumour substance beyond the femur, G. C. 3324. Presented &y Charles W. Cathcart, F.R.C.S.E. 6. 449. Central Sarcoma of the Tibia.— Part of a tibia — macerated, illustrating the above. The shaft is partially destroyed at one place, and shows a growth of new periosteal bone at others. This is apparently the result of the growth of a tumour similar to the last. Formerly described as " necrosis." G. C. 1161. Presented hy Professor James Russell. 6. 450. Central Sarcoma at the Lower End of the Femur. — Section of the lower end of a child's right femur and adjacent part of tibia — in spirit, illustrating the above. "Janet S. , aged 9, was ailmitted to the Royal Infirmar)', Edinburgh, on 14th September, suffering from a great swelling of the right knee. "The swelling is of a hard, elastic nature, with large superficial veins. The thigh of the same side is a little swelled, but not pained or inflamed. Central Sarcomata. 385 " She reports that the swelling commenced in the month of May last, without any apparent cause. Leeches, blisters, yeast cataplasms with sweet oil, were applied before her admission, without any effect. " On the 17th the limb was amputated about the middle of the thigh, the limb being removed, and the vessels secured by ligatures. The edges of the stump were brought together and secured in apposition by adhesive strap and bandage. "The patient did well at first after the operation, but about 20th October the surface of the stump gradually opened, and a fungus of a greenish colour and foul character protruded. The inguinal glands being diseased, she was considered incurable, and dismissed accordingly. "On dividing the tumour longitudinally, by sawing through the lower end of the femur, patella, and head of the tibia, the end of the femur appeared softened and somewhat enlarged, with a fungoid excrescence on its fore part. The surrounding muscles are altered in appearance. The cavity of the joint was but little affected, and the cartilages entire within." The section shows a central tumour, which has destroyed the interior of the bone and passed extensively beyond and around it. The soft parts are infiltrated behind, but there is a semblance of a capsule in front. G. C. 773. Presented hy Sir George Ballingall. 6.451. Central (?) Sarcoma of the Lower End of the Femur. — Section of the lower end of a right femur — in spirit. The bone has been partially destroyed by the growth of a tumour, which seems to have started in the interior, and to have bulged posteriorly. Formerly this specimen was described as part of a femur " carious from the pressure of a sac of blood." G. C. 984. 6. 452. Central (?) Sarcoma of the Lower End of the Femur. — Other part of the same femur — macerated, to show alterations in the bone. 2 B 386 Diseases of Bone. Above the condyle the interior is rarefied in some places and condensed in others. The surface of this affected part is somewhat rarefied, while above and below the rarefied area there is a crust of new periosteal bone. G. C. 984. 6/453. Sarcoma in the Stump of a Femur, after Amputation. — Portion of a femur — in spirit, illustrating the above. The patient was a marine, in wliom a very large tumour, 23 inches in circumference, had grown from the upper part of his left leg, between the 5th Jlay, when his leg was jammed, and the end of September, when the note was taken. The leg was amputated on the 5th October, and he died on the eleventh day after of tetanus, the stump, however, having been very unhealthy, with frequent secondary lipemorrhage, for several days before. The tumour had apparently been a sarcoma of the most malignant kind growing from the upper part of the fibula. There is a large fungous projection of tumour substance from the lower end of the medulla, i.e. where the bone was divided at the amputation ; while the medulla at the other end is seen to be full of the same material. (See case of Robert Lane, Bell's " Surgical Eej)orts and Observations," p. 386.) B. C. I. 6. M. 30. SARCOMA FOLLOWING FRACTURE. 6. 454. Central Sarcoma of the Femur, following- Frac- ture.— Section of the broken ends of the right femur of a man aged 4.5 — in spirit, illustrating the above. " This man Is of middle stature, muscular, but not fat ; his visage is particularly thin, and it has a foul yellowish colour ; he has dark eyes and black hair. " About nine months ago he broke his thigh-bone. The bone was knit together ; he fell and broke it a second time at the same place. After the usual period of confinement, the bone being united, a tumour rose gradually in the very centre of the thigh. It was attended with great pain. It has uniformly and imperceptibly increased, imtil now that it forms a tumour measuring three times the circle of the natural thigh. Sarcomata following Fracture. 387 It occupies the middle of the thigh, and surrounds the femur, and projects nearly in an equal degree on all sides. "There are here some peculiar circumstances, and a distressing alternative is offered to us. The tumour has all the appearance of fungus hfematodes, or soft cancer. To the feeling it conveys the notion of a soft spongy mass, distending the fascia of the thigh. It is evidently under the muscles, and the vasti rectus and sartorius muscles bind it so as to give it a peculiarly irregular surface. The pain is very great, an incessant dull pain. AVhile he describes his pain as a dull sensation, and in this expression distinguishes it from the occasional sharp and shooting pain of some tumours, yet his sufferings must be great in degree, since he expresses a desire to lose the limb. He is a steady man, and although not obtrusive nor loud in his complainings, he expressly wishes to lose his limb, although he sees that in order to do this it must be cut off close to his body. The skin has already assumed that light jaundiced colour, which on former occasions I have found to mark that the constitution is tainted with the disease. "On the other hand, here is a tumour arising distinctly from an accident, and there is a possibility that the tumour so arising may not be that formidable disease which we apprehend. In the meantime the growth of the tumour is so rapid that an operation will soon be quite impossible. If it should prove to be tumour of the bone, possessing no malignant character, of which we see examples, amputation will save his life. Even if the disease be of the nature of soft cancer, the operation affords him a chance of life. No condition can be an aggravation of his present state. "A consultation having determined on the operation, it was per- formed in the following manner." (The leg was amputated, and on the tenth day after the patient ■died from secondary hemorrhage. ) ""When the muscles were dissected off, the tumour was found to surround that part of the bone which had been fractured. It consisted of a cartilaginous substance, which, when cut through the middle, exhibited a well or cavity containing blood. The rest of the tumour was a soft, ^ulpy, greyish mass, too delicate in its texture to be preserved in spirits. A section was made of the bone and the tumour ; and when the parts were some days macerated, it was found that the bone was extensively diseased, and a peculiar semi-transparent matter of a grey colour filled all the cells of the bone ; and now it appeared that the bone had been first diseased at the fractured part, and that from thence the disease had propagated itself in all directions. " Examination of the Stump and Body. — On opening the face of the stump, both the femoral artery and the profunda were found secured by liga- tures ; a firm clot was found in the femoralTartery, and the cause of haemorr- hage was nothing in common with ^vhat is called secondary hsem.orrhage. On tracing one of the branches of the profunda, it was found to open, and, as it were, expand into a cavity containing blood. The substance surround- 388 Diseases of Bone. ing this cavity was of a nature similar to the great mass of the tumour. There is little doubt that a small part of the tumour had been left, or that the muscles, tainted b}' the contact, had propagated the diseased action. The diseased portion, increasing with that rapidity which characterises this sort of tumour, had destroyed the coats of the vessel, and from this sprung the haemorrhage which proved fatal. Had the tumour been entire, the blood would only have run into the interstices of its texture, but being open and upon the face of the stump, the blood had free egress. The cavity on the stump was in all respects similar to that found in the centre of the tumour. " On dissecting out the head of the femur, and sawing it through and macerating it, the disease was seen to have propagated itself to the head of the bone and through the whole cancelli." The broken ends of the bone are seen over-lapping, and apparently at one or two places united by bone. The greater part of the interval between the broken ends, however, has been occupied by the tumour substance ; some of it has fallen away, but what remains is soft, grey, and somewhat translucent. This material can also be seen occupying the medullary cavity above and below the seat of fracture. (See case of Phineas in Bell's "Surgical Observations and Eeports," p. 376.) B. C. i. 1. M. 33. 6. 455. Sarcoma of the Femur, following- Fracture. — Keproduction of plate ix. in the above-named volume by Sir Charles Bell, showing the appearance of the tumour before amputation. G. C. 3593. 6. 456. Sarcoma of the Femur, following- Fracture.— Section of lower end of the femur from the previous case — in spirit. The infiltration of the medulla by the tumour substance is well shown. B. C. i. 6. M. 29. 6. 457. Sarcoma of the Femur, following- Fracture. — Section of the stump of the femur, left after the amputation in the pievious case — in spirit. Sarcoma following Fracture. 389 The infiltration of the tumour substance into the cancel- lated tissue of the neck is easily seen. B. C. i. 6. M. 28. 6/458. Sarcoma of the Femur, following- Fracture.— Section of the loAver end of a right femur — in spirit, illustrating the above. In these two last preparations (see series 3. 247) we have instances of a circumstance, which I suspect not to be uncommon, fungus ha-matodes taking place in the bone after fracture of it." (Bell's M.S. Catalogue.) The lower end of the upper fragment has projected into the front of the knee-joint, and has pushed down the patella before it. The interval between the broken ends of the bone is occupied partly by fibrous tissue and partly by the tumour substance, now shrivelled and blanched by the spirit so as also to look fibrous. B. C. i. 1. M. 33. b. 6. 459. Sarcoma of the Humerus, following- Fracture.— Section of the upper end of a left humerus — in spirit, illustrat- ing the above. From a patient in whom "fungus tumour" formed after fracture. There is a sarcomatous tumour at the broken end, which has grown partly in the medulla and partly under the periosteum. G. C. 335. Presented by William Newbigging, F.R.C.S.E. 6. 460. Sarcoma of the Humerus, following- Fracture.— Other half of the previous specimen — macerated. K'ear the seat of fracture there is a slight periosteal crust, but the original bone inside has been rarefied. G. C. 335. Presented by William Newbigging, F.R.C.S.E. 6.461. Sarcoma of the Humerus, following" Fracture.— 390 Diseases of Bone. Section of the lower end of the same humerus as the last — m spirit, illustrating the above. The tumour growth can be recognised passing down the medulla towards the elbow. G. C. 336. Frese?ited by y^ ilIjIAM Newbigging, F.R.C.S.E. 6. 462. Sarcoma of the Humerus, following" Fracture. — Part of the soft portion of the previous tumour, with adjacent muscles — in spirit. "Its tissue is medulliform, interspersed with bony sj)icules and nodules of cartilage." The muscles are being infiltrated all round ; at one place in the interior, the tumour is breaking down. G. C. 335. 6. 463. Sarcoma invading" the Tibia.— Upper part of the left leg of a young man- — in spirit, illustrating the above. "This young man was a sailor, and three months before the appearance of the tumour of the leg, he received a blow on the upper part of the shin by the recoil of a gun. He does not attribute the growth of the tumour to this hurt, and it was only by questioning him as to all probable causes that this circumstance was brought to his recollection. The tumour extends from the middle of the tibia to the tendinous insertion of the patella into that bone. It surrounds the tibia and the head of the fibula, and evidently goes round to the back of the bones, for it has distended the gastro-cnemius and the soleus muscles. Its surface is distinguished by seven or eight distinct knobs or tubercles, which are soft or yielding, and give no indication of solidity or of scirrhous hardness. The tubercles on the lower part of the tumour have more firmness and solidity than these above. The surface is of a dark reddish colour ; the centre of the tubercles being of a yellowish colour, but crossed with numerous small veins, which give a venous or purplish- tinge. The tumour has been two months of acquiring its present magni- tude, and is not accompanied with pain. " When this young man had been a few days in the Hospital, and when I had ascertained the disease to be that most mortal of tumours, the fungus tumour, called soft cancer, I informed him of his danger. He was surprised that I should consider it so seriously, but threw himself entirely into n. y hands. In these circumstances such confidence only adds to the Sarcoma invading Bone, 391 oppressive feelings which the anticipation gives rise to. At this time he- had neither pain nor lameness. "Co«si(Zte ulcerated and discharged a limpid fluid. The glands of the groin have enlarged very considerably, and they are tender. Do these circumstance* warra°nt amputation, and what is the chauce of saving the life 1 My colleagues look less despairingly on this case than I confess I do. It may be possible that the glands of the groin are inflamed only in consequence of the leech bites and blisters; but independent of this circumstance, I fear we shall see the disease take an unfavourable turn at the end of three months from its commencement. Amputation is determined upon as aflbrding the only hope of saving his life. "4th day after amputation.— The glands of the thigh and groin have subsided in a very remarkable manner. During the operation the muscles of the thigh were unusually pale. On the first dressing the surface was pale, although there was partial adhesion. On the second dressincr the stump looked well, and the patient's health and spirits were observed to be very good. But about the ninth day the stump looked ill : there came a profuse gleety discharge, and the granulations were pale. ''March lOii/i.— The report is 'He looks ill, and has had rigours ; here is the commencement of mischief. ' "12^/i.— For some days he has been looking ill, and falling low; he vomits everything he swallows. He has got some relief by the effer- vescing mixture with laudanum. His pulse is scarcely to be distin- guished. << 14!E, AND CONNECTIVE TISSUE. 8. 1. Muscular Fibres. — "A packet of muscular fibres, from a piece of salt beef, which had been boiled " — in spirit. B. C. IV. 1. N. 1. 8. 2. Relative Vascularity of Muscle and Tendon.— Part of a gastro-cnemius muscle and tendo-Achillis, injected with vermilion, dried, and mounted in turpentine to illustrate the above. The difference between the two in colour, and hence in vascularity, is very striking. B. C. iv. 1. N. 2. 8. 3. Arrangement of Muscular Fibres. — Rectus femoris muscle of " a child twelve months old " — dissected, and in spirit, to- illustrate a penniform arrangement of the muscular fibres. B. C. IV. 1. N. 3. 8. 4. Arrang-ement of Muscular Fibres. — Injected right 540 Relations of Muscles and Tendons. scapula, humerus, and clavicle, with the deltoid muscle of a child, dissected as a specimen of "a radiated muscle" — in spirit, firm. B. C. IV. 1. N. 6. 8. 5. Relation of Muscle and Tendon. — Bones of an injected right leg and portion of tarsus, with the anterior and posterior tibialis muscles from " a child before birth " — dissected, and in spirit, to illustrate the above. B. C. iv. 1. N. 4. 8. 6. Relation of Muscle and Tendon. — Injected left scapula and part of radius, with the biceps muscle of a child — dissected, and in spirit, to illustrate a two-headed muscle. B. C. IV. 1. N. 6. 8. 7. Relation of Muscle and Tendon.— Injected left scapula, humerus, and upper end of ulna with the triceps muscle — of a child — dissected, and in spirit, to illustrate a three - headed muscle. B. C. iv. 1. N. 7. 8. 8. Relation of Muscle and Tendon. — Injected lower end of right femur and os calcis, with the gastro-cnemius and soleus muscles of a child — dissected, and in spirit, to illustrate "a quadriceps muscle." B. C. iv. 1. N". 8. 8. 9. Structure of Tendon. — A tendo-AchiUis from an injected leg — in spirit, illustrating its component bundles, and the vascularity of its sheath. B. C. iv. 1. IST. 12. 8. 10. Tendon Sheath. — An injected finger dissected, and in spirit, to show the strong sheath which binds the flexor tendons to the phalanges. B. C. iv. 1. N. 9. . Structure of Tendon Sheath. 541 8. 11. Arrangement of Tendon within Sheath.— An injected finger, dissected and in spirit, to illustrate the splitting of the flexor sublimis digitorum for the passage of the flexor pro- fundus, and the reflections of the vascular synovial lining of the sheath upon the relatively non-vascular tendons. B. C. IV. 1. N. 10. 542 . Diseases of Muscles, Tendons, etc. SERIES IX. INJURIES AND DISEASES OF MUSCLES AND TENDONS, SYNOVIAL SHEATHS, BURS>C, AND FASOI^e AND CONNECTIVE TISSUE. MUSCLES AND TENDONS. 1. Injuries. 9. 1. Injury to Tendons. — Thumb and long flexor tendon — in spirit, illustrating the result of evulsion. The parts were torn off by being entangled in machinery. The specimen illustrates what has been often observed when fingers are torn oflf, viz. that the part which gives way is the attachment between the muscle and the tendon, rather than the tendon itself. B. C. 4. i. M. 5. 2. Diseases. I. Abnormalities in Growth or DEVELOPiMENT. Specimens wanted. II. Changes peoduced by Conditions affecting the Nutrition and Growth of Muscle and Tendon, A. Changes from Local Conditions affecting the Nutrition and Growth of Muscles and Tendons. For Disease, see Series 1. B. Changes from affections of the Nervous System. 9. 2. Atrophy of Muscle from Paralysis.— Humerus, part of scapula, and upper end of radius and ulna, with some of the muscles attached — in spirit, from a paralytic patient. The biceps muscle is reduced to a thin fibrous cord, and its tendons are correspondingly small. The coraco-brachialis, Degeneration of Muscle. 543 supra-spinatus, infra-spinatus, and siib-scapularius muscles seem completely degenerated into fibrous and fatty tissue, the triceps, however, being still fairly well developed, and presenting in colour and arrangement a striking contrast to the others. B. C. 4. L M. 1. 9. 3. Atrophy of Muscle from Paralysis,— Portion of the soleus muscle — in spirit, illustrating the above. The muscle has apparently been transformed completely into fat and fibrous tissue. The tendon, however, retains more of its natural appearance. B. C. 4. i. M. 2. C. Changes from Constitutional or other Conditions more or less obscure. 9. 4, Rider's Bone. — Anterior portion of a man's pelvis — dissected, and painted over with glycerine and corrosive sublimate, to illustrate the above. On both sides a strong spur of bone about half an inch in diameter and about two inches long projects from the front of the symphysis pubis just below the crest, and follows the direction of the adductor longus muscle. On the right side the muscles have been dissected off, and the bone on this side has been separated from the pelvis by a fibrous intersection which has been wrenched open. The mode of union is thus seen to have been an irregular form of synchondrosis. On the left side the origins of the muscles have been left, and it can be seen that besides the adductor longus, the greater part of the adductor brevis, and portions of the pectineus, the gracilis, and the obturator externus take origin from the new spur of bone. G. C. 3455. Presented by Professor John Steuthehs, 1893. 9. 5. Degfeneration of the Diaphragrm. — Portion of a dia- 544 Diseases of Muscles, Tendons, etc. phragm, formerly described as "a peculiar condensed state of the diaphragm " — in spirit. The condition seems to be one of great thickening — possibly tubercular — on the peritoneal aspect of the diaphragm, while the muscular fibre seems pale and firm. Possibly the peritoneal thickening may have interfered with the movements of the muscle, and so led to its degeneration. G. C. 611. Presented by Professor John Thomson. 9. 6. Degreneration of Muscles of Arm.— Transverse section of a forearm — in spirit, illustrating the above. "The integuments were indurated and tuberculated from the middle of the arm to that of the forearm, and the elbow and muscles of the forearm rigid. The hand and lower part of the extremity were much swollen and cedematous. On the forearm was a considerable ulcer, with abrupt ragged edges and foul surface. "The arm was amputated close to the shoulder joint, where the parts appear sound, but after some months a similar disease attacked the cicatrix of the stump, and gradually extended till the patient died." " The section exhibits the skin much thickened and having the appearance of scirrhus ; the muscles appear for the most part converted into a white substance like cartilage, retaining to a certain degree the fibrous form of muscle ; in other parts the muscle is seen pale, as if gradually passing into the cartilaginous state. The adipose and cellular membrane have disappeared, so that the muscles appear to be matted to each other, and to the diseased skin. The larger nerves and blood-vessels are seen passing through the parts unchanged." This may have been a general tuberculosis of the skin, with degeneration of muscle following disuse. G. C. 221. Presented fcy W. Newbigging, F.R.C.S.E,, and Professor J. W. Tuenee. III. Inflammatoey Diseases. 9. 7. Abscess in Muscle. — Portion of a muscle, possibly rectus femoris — in spirit, illustrating the above. Tuberculosis of Synovial Sheaths. 545 Within the muscle there is a large cavity, with a definite wall, which has a somewhat flocculent lining. This has pro- bably been a tubercular abscess. B. C. 4. i. M. 4. IV. New Growths. Specimens "Wanted. Synovial Sheaths. (Injuries.) Diseases. I. Abnormalities and II. Changes due to Alterations in Nutrition AND Growth. Specimens wanted. III. Inflammatory Diseases. Inflammation due, 1 to mechanical injury, or 2 to ■pus-forming organisms. Specimens wanted. 3. Inflammation due to the Tubercle Bacillus. 9. 8. Tubercular Affection of Synovial Sheath, "Compound Gang'lion." — Cast in gelatine and glycerine of the front of a left wrist of a woman, illustrating the above. " Mrs. W., aged 41, was admitted to the Royal Infirmary, Edinburgh, in January 1891, complaining of pain and swelling in the palm of the left hand and wrist. Two years ago there appeared a swelling on the front of the wrist, unattended with pain, except undei' strong exertion. This remained unchanged until five weeks ago, when a swelling on the palm of the hand appeared also. The fingers became stitfer, and now she cannot grasp anything. Three years ago her foot was amputated for tubercular disease of the ankle. No other history of tubercle. Her family history is good. Incisions were made in the wrist and palm, and gelatinous and melon seed-like bodies scraped out." There is a distinct swelling of the front of the wrist and adjacent part of the palm, with a slight constriction opposite the position of the anterior annular ligament. G. C. 3371. Presented hy Charles W. Cathcart, F.R.C.S.E., 1892. 2 M 546 Diseases of Synovial Sheaths. 9. 9. " Melon Seed " Bodies from Tubercular Affection of Synovial Sheath, "Compound Gang-lion."— Numerous " melon-seed " bodies — in spirit. From a ganglion over the tendon of the extensor communis digitorum muscle. These bodies, often found in enlarged and thickened synovial sheaths, have been proved to be associated with the tubercle bacillus. B. C. ii. M. 36. 9. 10. "Melon Seed" Bodies from Tubercular Affection of Synovial Sheath, "Compound Gang-lion." — Numerous melon-seed bodies — in spirit. "These were evacuated by incision from the sheath of the flexor tendons of the middle finger. The patient, a man over 50 years of age, had suffered from this enlargement for six or seven years. Incision was made nearly over the heads of the metacarpal bones. The patient, at first, was greatly relieved." Besides well-formed loose bodies, others were found smaller, and in process of formation, showing the gradual development as enlargements from the inner surface of the synovial sheath, often in the form of fringes. G. C. 852. Presented by John Gairdner, F.R.C.S.E., 1826. 9. 11. Larg-e Gang-lion near the Wrist. — Plaster of Paris cast of the back of a left hand and wrist, showing an enlargement near the lower end of the ulna. The cast was originally entered as one of a diseased bursa, but from its lobulated character and position over the region of the synovial sheaths at the lower end of the ulna, it has no doubt been a ganglion, possibly associated with arthritis deformans. F. P. C. 2933. 9. 12. Very Larg-e Gang-lion near the Wrist.— Plaster of Paris cast of the back of a right hand and wrist, illustrating the above. Enlargement of Bursa Patellcv. 547 The chief swelling is over the lower end of the radius, but there is also a smaller swelling over the head of the ulna. The main swelling is markedly lobulated, and at some places rises into nobs. This was formerly described as a diseased bursa, but the cast itself has the word " exostosis " Avritten upon it. Probably, however, it was a ganglion, associ- ated with arthritis deformans, and so tense that it felt like bone. F. P. C. 293.3. Burs.t:. {Injuries.) Diseases. I. Aexormalities IX Growth and Development. II. Changes pkoduced by Alterations in Nutrition and Growth. 9. 13. Great Enlargement and Distension of the Bursa PatellSB. — A large sac, with a portion of the skin and under- lying soft parts, dissected from the front and outer side of a knee — in spirit. The patient, a woman aged 50, had been aware of the swelling for nineteen years. The main sac is lined by a somewhat flocculent membrane. Behind the sac there was a considerable thickening, composed of fibrous tissue, enclosing soft, friable material. This is a form of chronic enlargement of the bursa, the nature of which is obscure. G. C. 2751. Presented by A. G. Miller, F.R.C.S.E., 1885. 9. 14. Great Enlargement and Distension of the Bursa PatellaB. — Plaster of Paris cast of the previous specimen. Its circumference before removal was 16i inches. The cast shows the lobulated character of the growth, and its prominence on the front and outer side of the joint. G. C. 2751a. Pmc?i!!et£ &^ A. G. Miller, F.R.C.S.E., 1885. 548 Diseases of Bitrsce. in. Inflammatory Diseases. 1. Where the inflammation has been due to mechanical injtiry. 9. 15. Simple Chronic Inflammation of the Bursa PatellsBa — " Housemaid's-knee." Patella and ligamentum patellae, with thickened biirsae over it — laid open, in spirit. The walls are thickened, and are apparently lined with lymph, in process of organisation. B.C. 2. M. 23. 2. Where the inflammation has been due to action of pus-forming organisvis. Specimens Avanted. 3. Where the inflammation is due to the action of the tubercle bacillus. 9. 16. Enlarg-ement of Bursa Patellae, probably Tubercular. — Enlarged and somewhat thickened bursa patellae, with attached portion of the skin, from the knee of a young woman — in spirit. The patient had suffered from an obstinate form of housemaid's- knee for some years. As the condition was suspected to be tubercular^ Mr Cathcart excised the whole bursa, and the patient made a good recovery. The inner lining has numerous wart-like bodies growing from it. G. C. 3263. Presented by Charles W. Cathcart, F.R.C.S.E., 1891. 9. 17. Tubercular Enlargrement of the Bursa Patellae. — Sections of the right and left bursa patellae of a woman, showing thickening and distension of the wall — in spirit. Mrs M., aged 38 years, was admitted to the Royal Infirmary, Edinburgh, in May 1892, complaining of a solid swelling in the front of botli knees, limited to the region of the bursa. For three years the swelling on both knees, but especially that on the left, had gradually increased, apparently from the patient's having had an unusual amount of kneeling to do. Three months before admission a small abscess formed in the swelling on the left side, and after bursting formed a sinus, which continued to discharge. A fortnight before admission another abscess formed in front of the left swelling, but it had not discharged itself. The patient had had good health previous to the swelling, and had no Syphilitic Gamma of Bursa. 549 personal tubercular history, although one uncle had died of consumption. Both swellings were excised, and the wounds healed satisfactorily. When fresh, the thickening was gelatinous and soniewliat translucent in character. The cavity in each case contained right foot, illustrating the above. The patient, a healthy man of 28 years, stated that when 10 years- of age he fell from a height of twenty feet, and landed on his feet. For nine months after the accident he had been a patient in the Dundee- Infirmary, and for nine months more he had been unable to walk properly. After that, however, he quite recovered the use of his feet, although they remained deformed. He was under treatment in the Royal Infirmary,. Edinburgh, for fracture of the pelvis when this cast was taken. G. C. 2771. Presented by Charles W. Cathcart, F.E.C.S.E., 1887. 11. 42. Flat Foot. — Plaster of Paris cast of a left foot, showing: flat foot. The foot was somewhat shrunken, and the epithelium had peeled off before the cast was taken. The head of the astragalus forms a projection below the inner maleolus, while below and in front of the astragalus there is a projection formed chiefly by the scaphoid. G. C. 3238a. Fiat-Foot. 583 11.43. Flat Foot.— Dissection of the foregoing foot— in spirit. It will be seen that the head of the astragalus has slipped down from its proper place, and has carried the scaphoid with it. Considerable portions of the upper and inner facettes for articulation with the tibia have escaped from their contact with the tibia, while the cartilaginous area on the head, usually supported by the calcaneo-scaphoid ligament, is relatively much larger than usual. The tubercle of the scaphoid must have pressed through its covering of soft parts on to the ground. G. C. 3238. Presented by Henry D. Littlejohk, F.R.C.S.E., 1891. 11. 44. Normal Foot.— A normal left foot dissected in a way similar to the last to act as a standard for comparison with it. G. C. 3590. Presented hy Charles W. Cathcart, F.R.C.S.E., 1893. Miscellaneous Deformities. 11. 45. Deformity due to Spastic Paralysis.— Plaster cast of the left foot of a lady, illustrating the above. For 20 years she had sufifered from cerebral symptoms, i.e. giddi- ness, occasional falling, afterwards aphasia and gradual sinking. For 10 years before death she had suffered from spastic paralysis of the lower limbs. At the post-mortem examination a tumour (psammoma) was found opposite the internal auditory meatus on one side. The foot as a whole and the great toe are extended, and the four outer toes are flexed. G-- ^- 3412. Presented by T. Burn Murdoch, M.B., 1892. 11. 46. Bunion.— Plaster of Paris cast of a left foot, illustrating the above. The great toe points obliquely upwards and outwards. 584 The Zwibs as a Whole. The metatarsal bone is directed downwards and inwards, and the two form an angle at the metatarsal phalangeal joint, which is itself considerably enlarged and projects inwards. G. C. 3519. 11. 47. Knock-knee and Talipes Varus.— Bones forming the skeleton of the lower limbs of an elderly person — macerated, illustrating the above. The deformity has been much more pronounced on the left side. The upper ends of both femora show similar changes. The angle of the neck approaches a right angle in each case. The shaft is unusually straight, and a ridge of bone is prolonged from the spiral line along the inner side. The articular surfaces are normal. On the left side the shaft from the junction of the middle and lower thirds downwards has the appearance of having been bent outwards, and the inner condyle has projected markedly downwards. Part of the surface of the inner condyle has been injured in the process of maceration, but enough remains to show that its contour has been rounded. The contour of the outer condyle, on the other hand, is flat, as if the bone had been compressed. The articular surface of the outer ■condyle is irregular, and the margins show an overgrowth of bone, such as is seen in arthritis deformans. This latter change is seen also on the lower end of the right femur, which, however, may otherwise be considered as normal. The tibise, and especially the left, are both altered towards the upper end bj^ a twisting of the head of the bone inwards upon the shaft. In addition, on the left side the outer tuberosity has sunk markedly down, and the articular margins have irregular projections. The iTpper part of the shaft is distorted by an apparent flattening from before backwards. The fibulae have been bent forward at the lower end, and twisted with the tibia at the upper. The margins of the outer maleoli are irregular, and the grooves for the Knock-knee. 585 peroneus longus tendons are filled, up. Both feet, but especially the left, have been in a condition of talipes varus. On the outer side of the os calcis the groove for the peroneus longus is unduly prominent, especially on the right side, where new bone has been formed round it. The whole of the bones, but especially those of the left side, are light, soft, and greasy. G. C. 3489. Presented hy A. Miles, F.R.C.S.E., 1893. 11. 48. Genu-Valgum. — Left femur of an adult — macerated, illus- trating the above. The bone has been mounted in a nearly vertical position. The inner condyle is relatively much lower than the ou.ter. The increased quantity of bone on the inside is apparently just above the condyle. The centre of the articular surface of the condyle is similar. The upper end of the shaft is flattened from before backwards, and a strong ridge leads down from the neck along the inner side of the shaft. The neck itself is unusually horizontal. B. C. i. i. M. 21. 11. 49. Hammer Toe. — Toe and section of a toe — in spirit, illustrating the above. Both are in the condition known as hammer toe. The first inter-phalangeal joint is strongly flexed, and the other is extended. The head of the first phalanx is exposed, and the skin over it has been irritated by the pressure of the boot. The distal end of the soft parts of the toe is greatly enlarged in each case. G. C. 3243. Presented by A. G. Millek, F.R.C.S.E., 1891. 11. 50. Elephantiasis of Leg". — Plaster cast of the left foot and part of leg of a negro, affected with elephantiasis. The limb has been so enormously swollen, and the skin has become so thick and rough, that the appearance of a human foot 586 The Limbs as a Whole. is lost ; and the aptness of the term " elephantiasis '' is at once felt. The cast resembles the foot of an elephant much more than that of a man. G. C. 1821. Presented by Dr Robertson, August 1836. 11. 51. Elephantiasis of Leg". — Foot from which the previous cast was taken — in spirit. No number was attached to this specimen, but it is evidently the one from which the foregoing cast has been taken. The papillae of the skin of the foot are much exaggerated. The swelling has in many places been apparently due to oedema, for the skin can be pressed down upon the deeper parts as if it were an indiarubber ball. The papillae of the skin of the foot, except on that part of the sole which has borne pressure, are much exaggerated, and stand out individually as on a carnivorous animal's tongue. The bones of the leg where sawn across seem quite natural, without any appearance of enlarge- ment. The substance of the muscles is opened out, as if traversed by numerous channels. G. C. 1821a. Bupuytren's Contraction of the Palmar Fascia. 11. 52. Dupuytren's Contraction. — Plaster of Paris cast of a right hand — illustrating the above. The subject was a man 65 yeai's of age, alcoholic and gouty, but without having had any acute attack of gout. The condition was present for tliirty or forty years, and was sujjposed to have been caused by hard delving in Ceylon. He declined any operation. The cast shows a drawing down, especially of the middle finger, and a ridge formed by the thickened fascise, where it has- been stretched. The thumb is also partly drawn down. G. C. 3403. Presentedby T. Burn Murdoch, M.Ii., 1892. Dupuytren's Contraction. 587 11, 53. Dupuytren's Contraction. — Plaster of Paris cast of the left hand of the same patient as the last was taken from. The third and little fingers are flexed completely, and could only be moved a short distance from the hand. The thumb also is somewhat flexed at the first joint. G. C. 3404. Presented by T. Burn Murdoch, M.B., 1892. 11. 54. Dupuytren's Contraction.— Photograph of a right hand,, showing a marked contraction of the third and little fingers, before operation. The patient was an alcoholic man, aged 48. The condition, which had grown gradually worse, had existed for fifteen or twenty years, and waa supposed to have been due to lifting 56 lbs. weights in a sugar refinery. At first there was acute pain during the beginning of the flexion, but this passed away, and latterly there was no pain. The hands, however, were useless for manual work. G. C. 3405. Presented by T. Burn Murdoch, M.B., 1892. 11. 55. Dupuytren's Contraction. — Plaster of Paris cast of the hand shown in the previous case after the operation by division of the bands and stretching. It shows a marked improvement in both the affected fingers. G. C. 3406. Presented by T. Burn Murdoch, M.B., 1892. 11. 56. Dupuytren's Contraction. — Plaster of Paris cast of the left hand of the same patient, illustrating the above. There has been a slight contraction of the middle finger, and marked contraction of the ring and little fingers. There is a slight formation of a band on the palm, due to contraction of the fascia. G. C. 3407. Presented by T. Burn Murdoch, M.B., 1892. 588 The Lirribs as a Jl^iole. 11. 57. Clubbing" of the Ends of the Fing-ers.— Plaster cast of a left hand, illustrating the above. Tliere is an enlargement of the last phalanges, and an almond- shape of the nails. This is often associated Avith a tendency to consumption. G. C. 3067. Presented by Bryan C. Waller, M.D., 1889. 11.58. TubePCUlaP Dactylitis. — Gelatine and glycerine cast of the finger of a child, amputated for strumous dactylitis. The child had previously suffered amputation of the foot for tuber- cular disease. The disease was found to be confined to the soft parts, although frequently it is in the bone. G. C. 2791. Presented by P. H. MacLarek, F.R.C.S.E., 1888. 11. 59. Tubercular Dactylitis. — Section of the finger of a child, which was amputated for the above — in spirit. In this case the shaft of the first phalanx is entirely re- placed by a caseous mass. Another similar mass has lain beneath the skin on the palmar aspect. G. C. 3591. Presented by C. A. Sturrock, F.R.C.S.E., 1893. Gangrene. a. Dry Senile Gangrene — from Arterial Disease. 11. 60. Dry Senile Gang-rene of Foot— Early Stag-e.— Cast in gelatine and glycerine of the outer side of a left foot, to illustrate the above. A red discolouration has extended up to the ankle, while the toes and sole of the foot have begun to turn black. G. C. 2852. Presented by Charles "W. Catiicart, F.R.G.S.E., 1888. Dry Senile Gangrene. 589 11.61. Dry Senile Gangrene of Foot— Early Stagre.— Foot and leg of the previous case dissected, so as to show the state of the blood-vessels — in spirit. Both the anterior and posterior tibial arteries are atheromatous. Their coats are thickened and infiltrated with calcareous matter. Their lumen is diminished, especially that of the posterior tibial and its peroneal branch, and a portion of the posterior tibial artery is completely blocked with clot. The veins accompanying the peroneal artery are completely thrombosed, and patches of thrombosis can be seen in the posterior tibial veins. G. C. 2851. Presented by Alexander Bruce, M.D., 1888. 11. 62. Dry Senile Gangrrene of Leg- and Foot.— Left foot and part of the bones of the leg of an adult, dried, showing the results of dry gangrene. The man died of gangrene of the feet. The foot is shrivelled and black, and the posterior tibial vessels are by their irregularity evidently atheromatous and studded with calcareous particles. The bones have been sawn across. G. C. 354. Presented by Professor J. W. Turner. 11. 63. Blocked Vessels, which caused Dry Senile Gangrene. — The femoral artery, with its deep branch, from the same patient as the last was obtained from. The arteries have been slit up — in spirit. The coats are thickened all over, and deposits of blood clot here and there have obstructed the lumen. The cross section of the profunda shows a complete blockage. G. C. 351. 11. 64. Dry Senile Gangrene of Leg and Foot— Spontane- 590 The Limbs as a Whole. OUS SepaPation. — Lower portion of a left leg and foot — in spirit, illustrating the above. The patient was a very stout old woman, aged 78. She had shown premonitory symptoms iu both legs, i.e. cramps, pain and coldness, which were thought, at first, to be due to gout. The gangrene began in the great toe, and gradually spread up the leg until it came just below the head of the fibula, where a line of demarcation was found. Amputation was not performed owing to the patient having advanced heart and kidney disease. The dead soft tissues were therefore cut through just below the line of demarcation, and aia ineffectual attempt was made to destroy the bone by nitric and hydro-chloric acids. However, a month afterwards, the leg separated spontaneously. The stump healed over after a small fragment of dead bone had separated, and she went about on crutches and died 18 months afterwards of apoplexy. The soft parts are shrivelled and discoloured. The upper ends of the bones are irregular and rough, owing to the natural mode of separation by granulations. G. C. 3167. Presented by Dickinson Leigh, M.D., 1890. 11. 65. Dry Senile Gangrene of Leg" and Foot.— Lower portion of a left leg and foot — dried, illustrating the above. The soft parts separated spontaneously, but the bones were sawn through. The patient recovered. The specimen has the characteristic black and shrivelled appearance. The bones have been sawn across. Presented by Professor J. Y\. Turner. 11. 66. Dry Senile Gang-rene of Foot.— Greater part of a right foot — dried, illusi.rating the above. The separation has evidently taken place through the tarsus. The specimen has the characteristic black and shrivelled appearance. F. P. C. 1207. Presented by Professor John Thomson. 11. 67. Dry Senile Gang-rene of Fing-ers.— Right hand — in spirit, illustrating the above. Dry Senile Gangrene. 591 The fingers have been gangrenous in each case from the proximal end of the second phalanx onwards. A line of demarcation has formed, and the process of separation has been in progress. The arteries have been injected, and some colour- ing matter can be seen in the cross section of both the radial and the ulnar artery. G. C. 95. 11. 68. Dry Senile Gangrene of Fingcers.— Left hand — injected and in spirit, illustrating the above. Portions of the fingers and of the thumb have been gangrenous. The distal ends of the second phalanges of the fingers and the shrivelled end of the thumb project from the soft parts. A line of demarcation has formed upon the soft parts, but the bones had evidently not had time to separate. The end of the thumb was evidently about to separate at the joint. The injection has entered freely into the proximal ends of the fingers. G. C. 96. 11. 69. Dry Senile Gangrene of Hand.— Half-closed right hand, dried and varnished, illustrating the above. It is mummified, and of a brownish black colour. B. C. 4. I. M. 7. h. Moist Senile Gangrene. 11. 70. Advancing- Moist Senile Gang-rene of Foot.— A left leg and foot — dissected, and in spirit, illustrating the above. The patient, a woman aged 62, was admitted to Mr Miller's Ward , Royal Infirmary, Edinburgh, on 4th November 1889, suffering from moist gangrene of the left great toe which was advancing up the foot. A month before, while paring the great toe nail of the left foot, she had accidentally cut the toe. The wound inflamed and suppurated. She had severe pain in the foot, which was treated without benefit by poultices. After three weeks the pain gradually diminished and disappeared. The foot, however, got cold and black. On November 7th the leg was amputated above the knee, and on the 9th she died. 592 The Limbs as a Whole. The discoloured and sloughy condition of the great toe is well seen, but the discolouration which existed upon the other toes and on the dorsum of the foot has been removed by the spirit. The arteries were injected with vermilion and tallow. The injection has run down the anterior tibial artery as far as the dorsum of the foot, but beyond that only a little has been able to penetrate. The coat of the anterior tibial artery is atheromatous and filled with calcareous plates the whole way. On the posterior aspect, the injection has penetrated only to the level of the upper third of the leg, in the posterior tibial artery, and to about the middle of the leg in the peroneal artery. Beyond these points both vessels are so much con- tracted that the injection could not flow in them. Their coats are studded with calcareous plates in a manner very similar to that found in the anterior tibial artery. It may be noted, more- over, that the parts near the anterior tibial artery have received the injection down to, although not beyond, the ankle, whereas the injection posteriorly has only reached as far as the middle of the calf. G. C. 3148. Presented hij A. G. Miller, F.K..C.S.E., 1890. 11. 71. Advancing- Moist Senile Gangrene of Foot,— Left foot and greater part of a leg, blood-vessels dissected — in spirit, illustrating the above. The patient was a man, aged 70. The condition began in the great toe, and it was amputated. The mischief returned, and lie had a slowly increasing septic absorption from inliammation and suppuration of the foot, with great pain and sleeplessness. The leg was amputated below the knee, but the patient died three or four days afterwards. There was little or no bleeding from the vessels at the oi)eration, probably because they were blocked near the bifurcation of the popliteal artery. On dissecting out the arteries, the posterior tibial was found to be obliterated at its upper end by what seems to have been an old-standing clot, now apparently incorporated with the walls of the vessel. Below that point the vessel has Moist Senile Gangreiu. 593 shrunk, but its luiuen is still recognisable. The vessel wall throughout its whole extent is infiltrated with calcareous particles. The peroneal artery is likewise obliterated at its upper part, but the clot seems more recent. Lower down the condition of this vessel is similar to that of the posterior tibial artery. The veins were found empty and are nowhere throm- bosed. The anterior tibial artery is obliterated at its upper part, while lower down its lumen is contracted and is in places obliterated. The gangrenous and sloughing state of the fore- part of the foot is well shown. The great toe was amputated at a previous operation. G- C. 3377. Presented by Chaeles W. Cathcakt, F.K.C.S.E., 1892. 11. 72. Moist Senile Gangrene of the Foot and Leg-.— Lower part of a left leg and part of foot, blood-vessels dissected— in spirit, illustrating the above. The forepart of the foot was removed for convenience in mounting the specimen. The patient, a woman aged 68, had a history of gradually increasing debility for a year, but with no premonitory symptoms of gangrene in the limb. A severe pain in the left foot and lower half of the left leg occurred suddenly, four months before her admission to the infirmary. Three days later the foot grew cold. The pain increased, and discolouration of the parts began. The latter gradually increased, but the pain subsided. There was no known cause for the onset of the disease. The leg was amputated, and the patient made a good recovery. The posterior tibial artery is completely blocked at its upper part by a firm clot, which has apparently become adherent to the walls. The blocking continues down to about where the peroneal artery is given off. The continuation of the posterior tibial artery was accidentally removed in dissecting the specimen, but a small portion left at the upper end shows the vessel to have been greatly contracted. Its coat is thin, and only a few particles of lime salts can be felt upon it. The peroneal artery, although the larger of the two, is small and contracted, and its interior is occupied by a fine clot. Its coat also is only slightly thickened, and contains but few calcareous particles. 2p 594 The Limhs as a Whole, The posterior tibial vein at its upper part seems to have been thrombosed during life. The anterior tibial artery is somewhat contracted ; its coat thickened, and contains a few calcareous particles. In the interior there was a loose clot in many places. The discoloured gangrenous portion is separated from the rest of the leg by a line of demarcation. The tissues in the gangrenous part are soft and oily from degeneration,, while those in the upper part are dry and free from oil and fat. This seems to have been a case of embolus of the artery rather than of thrombosis. G. C. 3147. Presented by A. G. Miller, F.R.C.S.E., 1890. 11. 73. Moist Senile Gangrene of Foot — Separated.— Gangrenous foot of an adult — in spirit, illustrating the above. The sloughy condition of the specimen is well shown. It is still discoloured, although much of the colour must have been bleached by the spirit. The foot has separated at the ankle joint. G. C. 2712. Frescnted by William Newbigging, F.R.C.S.E. 11. 74. Moist Senile Gangrene of Hand and Forearm.— Left hand and forearm — in spirit, partially dissected to illustrate the above. The patient, a woman aged 79 years, was an inmate of a workhouse. The medical attendant's report was as follows : — "She had fatty degeneration of the heart's muscle, and extensive atheromatous disease of blood-vessels, and occasionally had fits of an e[>ileptic character, due, I think, to localised brain softening. Her last illness dated from July 23rd, when she fell over the bed while asleep, and sustained an injury to the left arm. The trouble began in the fingers, and spread gradually to the hand and arm, assuming all the appearances of moist gangrene. She was comatose two or three days before death, which took place on 13th August 1888." The arm was decomposing and putrid during life. The tissues in the gangrenous part are oily and soft from decomposition. Moist Senile Gangrene. 595 The brachial artery, when laid open, was found to be atheromatous, and at its bifurcation had fibrinous clots, which partly obstructed its lumen. The upper part of the ulnar artery was patent, though atheromatous, but in the upper end of the radial artery a firm clot completely occluded about an inch of the lumen. On the radial side of the limb the gangrene extends higher than in the ulnar side. Moreover, on the radial side, and posteriorly, the line of demarcation is complete ; while on the ulnar side, and anteriorly, it is incomplete. These differences on the two sides may be associated with the differ- ence in the patency of the respective arteries. Attention is directed to the important parts of the arteries by means of blue rods. This specimen may be taken as an illustration of what is probably always the case in moist senile gangrene, i.e., that besides a greatly impaired condition of the local circulation, there is a septic fermentatiozi in the tissues. On this account, so long as any circulation remains, it is in a condition of inflam- mation. The tissues, moreover, which from their impaired nutrition were unable to resist the entrance of sepsis, soon die after it has been established. Thus an area of septic inflam- mation once begun rapidly advances and soon ends in gangrene. By the time the process has passed through the region whose circulation has primarily been impaired, the patient may have sunk from septic absorption, or the even previously well- nourished tissues may have become hopelessly saturated with decomposing fluids from the part beyond. The general svmptoms of moist senile gangrene may be traced to septic absorption and pain. G. C. 2792. Presented by G. M. Johnston, M.D., 1888. Othei' Forms of Gangrene. 11. 75. Gangrene from Constriction. —Left leg and gangrenour, foot of a child — in spirit, illustrating the above. The foot and leg liad been put up in plaster of Paris. After several weeks the child was brought back, and when the plaster case was removed 596 The Limbs as a Whole. the foot dropped out. The leg was afterwards amputated below the knee. The foot had become gangrenous from constriction, and had separated by natural processes at the lower epiphyseal lines of the tibia and fibula. G. C. 3140. Presented by Macdonald Bkown, F.R.C.S.E., 1890, 11. 76. Traumatic Gangrene, uncomplicated by Sepsis. — Little finger — in spirit, illustrating the above. The patient was a mill girl, whose hand had been severely crushed by machinery. The injured hand was treated bj' immersion in an antiseptic bath, and septic fermentation was entirely obviated. The finger was removed several days after the injury by clipping through some remaining tags of skin and tendon. G. C. 3102. Presented by D. A. Carruther.s, M.D., 1888. 11. 77. Traumatic Gangrene, complicated by Sepsis.— Gelatine and glycerine cast of a right leg and foot, illustrating the above. The patient, a strong labourer, had his foot crushed by the fall of a heavy stone, and he was admitted to the Royal Infirmary, Edinburgh, on the same night. The next morning the foot was cold, and gangrene was feared. By the fourth morning after the accident, gangrene of the foot had become pronounced, and as it seemed to be spreading up the leg, ampu- tation was performed above the knee. The patient made a good recovery. The tissues in the foot were decomposing. The posterior tibial artery was found to be ruptured, the soft parts much bruised, and the os calcis crushed, while there was a severe Pott's fracture of the fibula Avith wrenching off of the inner malleolus. See ^o. 3. 313. The cast shows the discolouration of the foot, the blebs which appeared, and the peeling off of the epidermis. Above the ankle there were several blebs and much discolouration. Tnis, it was feared, showed advancing gangrene, but it may have been due only to extensive extravasation. G. C. 2850. Presented by Charles W. Cathcart, F.R.C.S.E. Gangrene. 597 in 11. 78. Gangrene from Frost Bite. — Forepart of foot i which the toes have been killed by exposure to cold— in spirit. The line of separation, formed by ulceration, is complete in the skin, and is in progress in the deeper tissues. Some portions of the extensor tendons still remain on the dorsum. The metatarso-phalangeal joint of the great toe is exposed, and the head of the first metatarsal bone is bare, and has probably been in process of separation. The toes are apparently but little changed. They had probably been killed outright, and had not had time to shrivel and dry up. G. C. 225. 11. 79. Gang-rene from Burn. — Forefinger injected and in spirit, illustrating the above. From an old man who had fallen into the fire and burned his hanil severely. The end of the fiuger is gangrenous, and the parts behind,, which were living, have inflamed and ulcerated, and have thus formed a line of demarcation. G. C. 2861. Presented b>j A. G. Miller, F.R.C.S.E., 1888. 11. 80. Gang-rene from Acute Septic Poisoning-. — Little finger — in spirit, illustrating the above. From the hand of a workman, aged 50, who had received a severe cut of his thumb. The wound having become septic, inflammation spread over the whole hand and up the forearm, and ended in extensive suppura- tion and sloughing, with gangrene of this finger. It became shrivelled and dry before it was removed. The ligaments at the meta-carpo phalangeal joint had been destroyed. Granulations have eroded the surface of the proximal end of the first phalanx. G. C. 3156. Presented by Charles W. Cathcart, F.R.C.S.E., 1890. 11. 81. Intra-uterine Gangrene, with Spontaneous Am- 598 The Limhs as a Whole. putation. — Infant's right forearm and part of the upper arm — in spirit, illustrating the above. It was hanging by a thread at birth, and was separated by a snip with scissors, without bleeding. No cause for the condition could be traced in the arrangement of the umbilical cord or otherwise. The infant was one of triplets. A process of intra-uterine mummification seems to have extended nearly to the elbow. G. C. 2833. Presented hj G. M. Johnston, M.D., 1888. Stumps after Amputation. a. Anatomj\ 11. 82. Stump after Amputation throug-h the Upper Arm. — Stump after the above — dissected and in spirit. George M , aged 26, had his arm crushed by a stone weighing about 30 cwt. , which was lowered too rapidly while he was smoothing the mortar for its bed. The forearm and elbow-joint were severely injured. A local doctor bandaged the arm, and the patient arrived at the Royal Infirmary, Edinburgh, at about 7 p.m. on 19th August 1890. Mr Cathcart amputated the limb 3J or 4 inches above the condyles. About 1st September, when the wound was nearly healed, the patient showed signs of tetanus. On the morning of September 3rd Mr Cathcart performed Spence's amputation at the shoulder-joint. The tetanic spasms, which had been very severe, improved for a time, and the patient Ml asleep at 1 p.m. He woke, however, at 1.45 p.m., and after three spasms, died in a fourth, which was prolonged. The end of the median nerve is slightly enlarged, the end of the brachial artery has been filled by a clot, and its termination has been surrounded by organising lymph. The wound had almost entirely healed, and the section shows how the skin had covered in the cut end of the muscle. G. C. 3204. Presented by Chakles W. Cathcaet, r.R.C.S.E., 1890. 11. 83. Stump after Amputation above the Elbow.— Stump Anatomy of Stumps. 599 of a left arm after the above, injected Avith coarse injection and dissected — in spirit. This amputation was performed for epithelioma of the hand and forearm. A second amputation, which was at the shoulder -joint, was performed nine weeks after the first, for a recurrence of the disease in the axillary glands. The man died soon after the second operation. The brachial artery, which is injected, is seen to tail off into fibrous tissue (green rod) below its last branch. The calibre of the vessel is not much altered in the greater part of its course. The main nerves have apparently been shortened at the operation. The cut end of the median nerve is slightly bulbous, and a filament from it passes in front of the artery. The end of the ulnar nerve is only slightly enlarged. A rod is passed below the ends of both the ulnar and median nerves. The end of the musculo-spiral nerve is not enlarged. A thick pad of subcutaneous tissue covers the end of the bone, which has been sawn up. The fibres of the supinator radii longus muscle are seen to run into fibrous tissue below. G. C. 2793. Presented by Professor T. Annaxdale, 1888. 11.84. Stump after Amputation at "the Seat of Elec- tion."— Sections of tibia and corresponding part of fibula of the above amputation — soft parts dissected, in spirit. The amputation was performed for sarcoma of the leg, which had attacked an ulcer. There was no return at the stump, but the patient died of deposits of sarcoma in the brain, heart, and lungs. — See No. 9.66. The end of the bone is covered by skin only. All the structures end in fibrous tissue. There are no enlargements of the ends of the nerves. G. C. 2817. Presented by C-s.k.v.\.^s W. Cathcart, F.R.C.S.E., 1888. 11. 85. Stump after Syme's Amputation. — Section passing through tibia and fibula of an injected stump after a Syme's amputation. 600 The Limhs as a Whole. An amputation through the leg was required for secondary haemorrhage some weeks after the first one ; the limb had been a paralysed one (see No. 6. 59.) The stump has healed well. The excellent covering for the bone afforded by the heel pad may be contrasted with that formed by the skin of the leg at the seat of election (previous specimen). G. C. 3173. Presented by A. G. Miller, F.R.C.S.E., 1890. 11. 86. Stump after Syme's Amputation. — Parts from a recent case of Syme's Amputation — in spirit. Reamputation was required on account of sloughing of the heel flap. The posterior tibial artery was represented by only a very fine twig, and its place was taken by a large branch growing outwards from the posterior peroneal artery. Granuiation tissue covers the end of both bones ; and the periosteum above the section is thickened and has been forming bone. The end of tlie tendo-Achillis is seen to be covered with lymph. The cut end of the posterior tibial nerve is enlarged. G. C. 2802. Presented by P. H. MacLaren, F.R.C.S.E., 1888. 11. 87. End of Bones after Syme's Amputation.— Portions of the tibia and fibula from the above case — macerated. New bone is seen to be forming on the cut surface of the tibia and on the surface of the shaft of both bones. G. C. 2802. a. Presented by P. H. MacLaken, F.R.C.S.E., 1888. 11. 88. Stump after a Syme or Pirogoff 's Amputation.— Knee-joint and stump of the leg below — dissected, and in spirit,, illustrating the above. Syme or Pirogoff's amputation had been performed early in life. Re-amputation was performed above the knee for disease of the knee- joint. Anatomy of Stumps. 601 The muscles are all atrophied, but the gastro-cnemius is the least so, and the soleus is next to it. The posterior tibial artery is smaller in proportion than the posterior tibial nerve, which has no bulbous ending. The os calcis has either been at first partly left, or has since been partly re-formed. The bone re- presenting it is separated from the tibia, partly by fibrous tissue, and partly by a false joint. G. C. 2798. Presented by Professor T. Annandale, 1888. 11. 89. Stump after a Syme or Pirogoff's Amputation.— Fibula and a small piece of the tibia, with a portion of the bone representing the os calcis, from the previous case — in spirit. An atrophied tendo-Achillis is attached to a fragment of the OS calcis, and between this bone and the bones of the leg there is an appearance of cartilage in the newly formed joint. G. C. 2798. a: Presented by Professor T. Annandale, 1887. 11. 90. Stump of a Femur a Year after Amputation.— Por- tion of the femur — macerated, illustrating the above. The original operation], was performed at the Military Hospital, at Portsea. Whether a secondary amputation was required, or whether the patient died from other causes, is uncertain, but from the appearance of the stump the latter seems more probable. The end of the bone is somewhat rounded ofiF, but the extremity has not been covered in. F. P. C. 229. 11, 91. Stump of a Femur long" after Amputation.— Small piece of bone — macerated, illustrating the above. The secondary amputation was performed on account of "irritable stump " (i.e. enlargement and painful condition of the ends of the nerves). The bone is greatly atrophied, and its extremity rounded 602 The Limhs as a Whole. and tapered ofiF. The linea aspera projects at the back, and its prominence is probably due to its having had muscles attached to it, which remained in use. B. C. i. 5. M. 48. 11. 92. Stump of Radius long" after Amputation. — Upper two-thirds of a radius — macerated, illustrating the above. The bone is light, and the muscular ridges are feebly de- veloped. The extremity is rounded off, but covered with a slight crust of new periosteal bone, which extends a little Avay up the shaft. B. C. 1. 5. M. 45. 11. 93. Stump of a Phalanx after Amputation.— First and part of second phalanx of a finger — macerated, illustrating the above. The piece of bone at the end of the phalanx seems to be the atrophied stump of the second phalanx, after amputation. G. C. 3313. h. Diseases in Stumps — Septic Changes. 11. 94. Stump of a Fibula which has been Inflamed.— Section of portion of a fibula — macerated, illustrating the above. The distal end of the bone has evidently been sawn across. New periosteal bone has formed for some distance above the lower end. The interior of the inflamed part is now filled with adipocere. B. C. 1. 5. M. 21. 11. 95. Stump of the Bones of a Leg" after Amputation Thickened. — Portion of a right tibia and fibula — macerated, illustrating the above. Both bones are considerably thickened, and some new peri- osteal bone has been formed for some distance up the shaft of Pathology of Stumps. 603 each, especially upon the tibia. A firm mass of bone unites their distal ends together. Possibly this condition has been due to a chronic ulcer on face of the stump. B. C. 1. 5. M. 43. 11. 96. Stump of a Femur, with Necrosis and Thicken- ing".— Section of the injected stump of a femur — macerated, illustrating' the above. A small necrosed fragment at the end has been in process of separation, and a strong crust of new bone has been formed round the sawn extremity. W. C. G. 22. 11. 97. Stump of a Femur after Amputation. — Section of the injected stump of a femur — in spirit, illustrating the above. Round the sawu extremity there is a considerable crust of bone, which extends for some distance up the shaft, Avhile new bone has been forming across the end of the medullary cavity. The vascularity of the new bone is well shown by the injection. The large amount of new bone has, no doubt, been due to septic inflammation of the soft parts over the bone. B. C. 1. 5. M. 44. 11, 98. Stump of a Femur, altered by Chronic Septic Osteo-myelitis. — Enlarged end of a femur after amputation — macerated, illustrating the above. The lower end is rounded in shape, but its surface is irregular and is covered by a spongy carious bone. The whole shaft is greatly thickened. The original compact tissue cannot be traced. The wall of the medullary cavity is formed of bone, which is intermediate in character between cancellous and compact tissue. It is of irregular thickness. W. C. G. 23. 604 The Limbs as a Whole. 11. 99. Stump of a Syme's Amputation, affected by Tuberculosis. — Section of the tibia and soft parts of a left leg — injected with carmine, and in spirit, illustrating the above. The foot was amputated for tubercular disease of the ankle-joint. A re-amputation became necessary on account of return of the disease in the bone and soft parts. In the heel flap is seen a large abscess cavity, lined by granulations. In the interior of the tibia a condition of chronic tubercular osteo-myelitis tending to caseation is seen to have spread upwards from the sawn surface. G. C. 2872. Presented by P. H. MacLaren, F.R.C.S.E., 1888. Illustrations of the forms of Stumps. 11. 100. stump of an Amputation at the Shoulder-joint.— Plaster of Paris cast of a healed stump after amputation at the shoulder-joint, showing the cicatrix at the side of the chest. G. C. 3520. 11. 101. Stump of an Amputation at the Shoulder-joint. — Plaster of Paris cast of a healed stump, after amputation at the shoulder-joint, showing the cicatrix at the side of the chest. G. C. 3521. 11. 102. Stump of an Amputation through the First Phalanx of the Finger. — Gelatine and glycerine cast of a right hand — illustrating the above. The patient was an old woman, whose third finger had been ampu- tated through the first joint in earl}' life. The cast was taken in the extended position to show that the stump of the first phalanx extended equally with the other fingers. G. C. 2898. Presented by CiiAiiLEs W. Cathcart, F.R.C.S.E., 1888. Stumps after Amputation. 605 11. 103. Stump of an Amputation throug-h the First Phalanx of the Fingcer. — Gelatine and glycerine cast of the foregoing hand in the flexed position. This cast shows that the stump of the first phalanx flexed equally with the other fingers. G. C. 2897. Presented &?/ Charles W, Cathcart, F.R.C.S.E., 1888. 11. 104. Stump after Chopart's Amputation .—Plaster of Paris cast of a stump of a right foot, after the ahove operation. The cast shows that the heel has not been drawn up, and that the sole has been planted well on the ground. The arch of the foot has necessarily given way, but an admirable basis of support has been left, much better than that afforded by Syme's amputation. G. C. 3527. Presented hy OnKKh^s "W. Cathcart, F.R.C.S.E., 1893. 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