The idea of trephining the tibia in this case was suggested by a case which occurred at the Lock Hospital, during the period when I held the office of house-surgeon. A young and delicate woman, after other symptoms which it is unnecessary to detail, became subject to intense and uninterrupted pain in the right thigh. The disease was relieved by none of the means employed, and the patient at length, after most protracted and severe suffering, died, apparently worn out by the pain. On making a section of the bone, I found that its cancellous structure was occupied at different parts by a morbid deposit. This occurred in irregular patches, completely filled the cancelli, and was of a light brown colour. It was moderately firm in consistence, and upon a chemical examination by Dr. Beale, of Carey Street, was pronounced to consist chiefly of fatty matter. The parietes of the bone were greatly thickened, and a kind of cancellous structure had been developed between the original outline of the bone and the newlyformed portions.

The extreme distress which this patient endured arose probably from the tension produced by the interstitial deposit of bony matter: whether determined in this individual instance by the presence of diseased matter in the interior of the bone, or not, I will not undertake to say; but, in either case, it appeared probable that the pain which constituted the really serious part of the disease might have been relieved, had a sufficient opening been made in the bone. If the morbid deposit kept up the irritation and produced the surrounding thickening, an artificial opening might at once have afforded relief. The object of such an opening would be not necessarily to remove all the diseased matter in the interior of the bone, but that it might be dissolved and expelled in the subsequent suppuration. If, on the other hand, the real disease were independent of the deposit in the cancellous structure, the removal of a portion of the dense and hard crust of the bone would be the means most likely to relieve the tension of the parts. Such were the considerations which determined me, should an opportunity present itself, to try the effect of making an artificial opening in cases of long-continued pain in bone, not yielding to internal remedies, and following the action of a morbid poison upon the system. In such an experiment there is everything to be gained and nothing to be lost. For should the operation entirely fail in removing the symptoms, the patient is not left in a worse condition than before.

The morbid deposit in the interior of bones to which I have alluded, may, I believe, take place so as to occupy a large portion of their

cancellous structure; and that it then becomes a source of irritation in some cases, I cannot doubt, from the fact of openings being occasionally formed by a natural process of ulceration in bones long affected, as if to allow an exit for the morbid matter. These points are illustrated in the accompanying figure, for which I am indebted to Mr. Harrison, of the Albany Court-yard.

Fig. 7. Showing morbid deposit in bone, and ulcerated opening through its thickened wall.

In the class of cases now referred to, there may be no formation of pus in the bone. In this respect they differ from those previously mentioned. Independently, however, of the actual pressure of the confined fluid, the cases are strictly analogous. The essential characters of the disease may be the same, whether the original cause of local irritation arise from confined purulent fluid, or from a deposit of morbid matter in a more solid form, or from a piece of necrosed bone.

The following case, in which there was no suppuration and no external opening, presents an example of chronic irritation from necrosis, producing a very large deposit of new bone, and giving rise to some of the symptoms, although in a milder form, that were present in the cases of abscess in the tibia before related.

CASE IV. A. R., aged 24, was admitted into King's College Hospital, May 21, 1852. Twelve months previously, she had experienced much pain in the left leg. This was attended with swelling and redness extending over the whole limb. After a time, she went into Guy's Hospital, where she remained twenty-two weeks, and then returning home, continued without attendance for three months.

On admission into King's College Hospital, the two lower thirds of the left tibia were very much enlarged; the surrounding skin was red and tender upon pressure; she complained of pain in the leg, which at night was occasionally sufficiently severe to cause her to get up and walk about the room. Generally speaking, she found that the leg was easier when hanging down than at other times. There was no external opening, nor any apparent constitutional or hereditary disease to account for the symptoms. She was kept in bed for five weeks, and some internal medicines were given; but as no benefit appeared to be derived from these means, the operation of trephining the tibia was performed upon the 1st of July. It became apparent during the operation that the bone was very greatly thickened and condensed; and it was with some difficulty that the trephine was made to perforate its dense substance. When the first portion of bone was removed, the irregular rough surface of some dead bone could be felt beneath. It became therefore evident that the case was one of necrosis. The tre

phine, which was of small diameter, was now applied to different parts, so as to admit of a considerable portion of the newly-formed bone being removed by sawing between the openings. These would represent the corners, and the lines of the saw the sides, of an oblong. The portion of bone thus raised was half an inch thick at its thinnest part. Between it and the exposed and necrosed shell of the tibia there was no fluid whatever. A portion of the dead bone at the bottom of the wound was now removed in a similar way, and in the centre of the old bone was found a condensed and detached portion of dead cancellous structure. It is unnecessary to give any further details of this case, except to mention that, after the operation, the pain, as well as the redness of the skin of the leg, entirely subsided, and in less than two months she was sufficiently well to leave the hospital.

Strumous deposit in bone may in like manner become the source of chronic irritation and long continued pain. It is seldom, indeed, that crude tubercle is deposited in any quantity in bone, but the following case, for which I am indebted to Mr. Hewett, of St. George's Hospital, will serve to shew that when it does occur the symptoms will bear a certain resemblance to those of chronic abscess. A man was admitted into St. George's Hospital with a tumour situated at the union of the middle to the lower third of the thigh. This tumour was unyielding in its nature and not painful when handled. Fifteen months previously the patient had begun to suffer considerable pain in the bone, of a shooting character. This deprived him of rest at night. Three months afterwards the swelling made its appearance, and gradually increased in size; seven months from the time he was first attacked his health began to fail, and the pain in the thigh had, with few intermissions, been continual and of a severe character. The year following his first admission into the hospital, he was attacked with erysipelas, and died. On examining the thigh, great thickening and condensation were observed between the muscles and the bone. The periosteum, which was much thickened, presented, on its free surface, a large patch of tubercular matter, enveloped in a dense cyst. The bone itself was irregular in shape, much hypertrophied, and very hard. Its medullary cavity at this point was filled with tubercular matter, surrounded by gray semitransparent lymph. Deposits of scrofulous matter were also found in other parts.

From the examples now adduced it appears that long continued pain in bone may arise from a variety of different pathological conditions, and that the chronic irritation, which precedes the deposit of new bone, may depend, among others, upon the following local causes :-1. Upon the formation of pus within the bone. 2. Upon the deposition there of more solid material arising from the poisons of mercury, or syphilis. 3. Upon a collection of tubercular matter in bone; or 4, upon the presence of a necrosed portion of cancellous structure.

When the source of the continued irritation is thus situated within the bone itself, it seems not unreasonable to conclude that a similar plan of treatment would be available, from whatever cause that irritation may arise; and the results hitherto obtained would appear to lead to the inference that relief may be expected from an artificial opening in several classes of cases.

Wherever there is reason to suspect that pain in a bone is kept up

by the presence of some morbid or foreign matter in its interior, or by the pressure produced by a redundancy of bony deposit, it appears evident that the removal of a piece of the shell of the bone is the rational mode of treatment. An opportunity is thereby afforded at once for the escape of any confined matter, and the tension of the parts is relieved; and it appears not improbable, from the favourable effects hitherto obtained by this mode of treatment, that it may hereafter be extended to the relief of many cases of protracted and obscure affection of the osseous system.

13, Dover Street, Piccadilly, September 1852.

BIBLIOGRAPHICAL RECORD.

THE PHYSICAL DIAGNOSIS OF DISEASES OF THE ABDOMEN. By EDWARD BALLARD, M.D.Lond. pp. 276. London: 1852.

DR. BALLARD's work is divided into three parts, the first of which treats of the METHOD AND GENERAL RESULTS OF PHYSICAL EXAMINATION; the second, of the PHYSICAL SIGNS OF THE DISEASES OF THE ABDOMEN; and the third contains an ENUMERATION OF THE MOST REMARKABLE PHYSICAL SIGNS, WITH THE DISEASES BY WHICH EACH MAY BE OCCASIONED.

It is necessary to remark, that Dr. Ballard has included in his work the Physical Diagnosis of the Diseases of the Pelvis, for reasons which appear to us to be quite satisfactory, for, as he justly observes, the viscera of the pelvis often rise up so as to occupy the cavity of the abdomen; and, on the other hand, not only are some of the healthy abdominal structures prolonged into the pelvis, but the products of diseased action gravitate into this cavity. The introduction of the Physical Diagnosis of Pregnancy, although not a disease, is also, in our opinion, quite justifiable, and the directions given for the digital examination of the pelvic organs by the vagina and rectum add very much to the interest and importance of Dr. Ballard's treatise.

Five methods of physical examination are described by Dr. Ballard, viz., INSPECTION, by which much valuable information is obtained as to the positive and relative size, and as to the situation and movements of the abdominal contents; MENSURATION, by which an accurate result is afforded in confirmation of the knowledge gained by inspection; PALPATION, by which the size, situation, consistence, and other properties of organs may be estimated; PERCUSSION, which offers results in the abdominal organs of no less value than it yields in those of the thorax ; and AUSCULTATION, which although of comparatively limited application in the investigation of abdominal disease, yet in certain special circumstances, as in the determination of pregnancy and of arterial tumours, affords information of unquestionable importance. The following extract on the mode of inspecting the abdomen is of great practical value.

"In accordance with my former remarks, inspection must take in simultaneously the abdomen and the chest. Both must of course be uncovered and exposed in a good light, the subject being protected from cold by a previous regulation of the temperature of the room. This is essential, not only for the benefit of the person examined, but because a sensation of chilliness is incompatible with that perfect rest which it is desirable that the abdominal and thoracic muscles should maintain during the period of inspection. The position of the subject may be either the erect or the recumbent.

In disease, the latter is often the only available one; but when possible, the erect posture is often to be preferred. Whichever posture is selected, the arms should hang or lie loosely by the side; the subject should stand on a level surface, or lie upon an elastic but moderately resistant mattress; the carriage of the head should be unconstrained, or, if the patient be lying, it should be supported at the same angle with the trunk as it holds in the erect position. Above all, the physician must not allow the examined to take the place of the examiner; his eyes must be kept directed to some object, either in front of him, or, if he be lying, to the ceiling. An infringement of this rule is often fatal to the accuracy of either inspection or measurement; for, almost involuntarily, some of the muscles will be thrown into activity, or the natural movements be disturbed, when the person directs his attention to them."

In the section devoted to the Exploration of the Pelvic Organs by the introduction of the fingers into the canals of the rectum and vagina, we find that Dr. Ballard recommends the supine posture as the best for the purpose of physical diagnosis, as "the obstetric position upon the left side, adopted by some practitioners from motives of delicacy, is open to many practical objections, the most serious of which is, that the back of the finger comes in contact with the anterior part of the vaginal wall, and there is so much difficulty in turning it, that signs of disease on that side may easily escape detection." The author expresses a modified approval of Simpson's uterine sound, which, he thinks, is indispensable in certain cases, for arriving at a correct diagnosis. "The points which are to be ascertained by it are, the length of the uterine cavity and its direction, the mobility of the womb, and thus its attachments to other structures or organs within the simultaneous reach of the examining finger, of the finger placed within the rectum, or of the hand above the pubes. The thickness of the wall of the uterus may often thus be estimated at the spot which corresponds to the extremity of the sound. Accidents have arisen in connexion with its employment, and even metritis has been said to have been occasioned by it. I have met with none of these, however, in my own practice. It need scarcely be said that the suspicion even of pregnancy must decidedly negative its employment, and that, when used, all roughness of manipulation must be most carefully avoided."

In the Second Part of the work, the various Diseases of the Abdomen are considered, so far as they are capable of being distinguished by physical signs; and, as we have before remarked, this portion is rendered still more interesting by its being made to include the investigation of the puerperal state, and of the diseases of the pelvic viscera. In this section, Dr. Ballard describes the displacements of the bladder and the distension of that organ; inflammation and abscess of the pelvis, and the various displacements of the unimpregnated uterus. He then describes very carefully the physical signs of ordinary pregnancy; and in discussing the auscultatory phenomena of this state, he attributes the murmur, formerly known as the placental souffle, either to the peculiarities of the uterine circulation, or to a variety of causes, among which may be considered the effect of pressure excited by the enlarged uterus upon the iliac vessels.

A chapter is devoted to the Physical Diagnosis of Extra-Uterine Pregnancy; and although it must be admitted that the signs of this formidable complication of the puerperal state are very unsatisfactory, yet we must give credit to Dr. Ballard for having brought together, we believe for the first time, all the circumstances which may strengthen our conjectures as to the existence of such an accident.

The chapter on Fibrous Tumour of the Uterus, including Fibrous Tumour superadded to Pregnancy, reminds us of a curious case which lately happened in our own practice, and in which the diagnosis, before delivery, must have been very obscure. A single woman, aged 45, a servant, was brought into a

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