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and left the hospital one month after the operation, her 1health rapidly improving, and the knee free from pain. ’

Two months afterwards, (about three months after thetrephining,) she presented herself again, and it was ascer-tained that she could now walk with great comfort, and hadnot had any return of the peculiar pain which for years hadbeen causing her so much distress.

Trephining of the Tibia for Necrosis, unconnected with anytegumentary solution of continuity.(Under the care of Mr. LEE.)

This patient, about twenty-four years of age, was admitted,May 21, 1852, complaining of severe pain in the left tibia.She had been suffering in the leg for the last twelve months,and had been under treatment at Guy’s Hospital, whereactive antiphlogistic means had been used at first. She re-mained in that institution for twenty-two weeks, underwentvarious kinds of treatment, and after staying at home forsome time, without medical aid, she applied to this hospital.The left tibia was evidently enlarged through its two.-ower

thirds, there was redness of skin and pain, which latter wassometimes so severe at night as to drive the patient from herbed. The skin was not broken, and there was nothing inthe woman’s history to point to syphilis or hereditary taint.For about five weeks the treatment consisted principally inemollient applications, rest, and tonics; but the tegumentaryinflammation, which had somewhat subsided, soon re-

appeared, and the leg became codematous. Mr. Lee, there-fore, resolved upon trephining the bone, as he felt confidentthat the irritation was seated in its interior.On the 1st of July, the patient was narcotized with chloro-

form, and Mr. Lee applied a small trephine on the most pro-jecting portion of the affected tibia, after the skin had beenreflected. The walls of the bone were found considerablythickened, and much force was required to perforate themwith the instrument. When the latter had brought away acircular piece of bone, the cavity thus formed was felt to berough at the fundus. It was therefore plain that caries andnecrosis were going on within, and that the plate of bonejust perforated was the newly-formed shell. Mr. Lee de-termined, under these circumstances, to remove some more ofthe shell, so as to get easy access to the diseased portions ofthe bone.The trephine was consequently applied in three more

places, forming, with the first hole, a long square, and thebone was cut through with the saw along the lines of junction.A pretty large piece of new shell was thus removed, which,in its thinnest portion, was half an inch thick. A rough andplainly necrosed piece of bone was now brought into view,and taken away in the same manner as had been usedfor the outer shell. But at this stage of the operation it wasfound that the morbid process had extended to the oppositeside of the tibia ; both the elevator and the trephine werenow used, and Mr. Lee succeeded in removing all the deadbone that could be felt and seen. The wound was dressed inthe usual way, and the patient carried away after an operationwhich was necessarily protracted.The patient’s symptoms became now very favourable, the

reaessof the skin disappeared, the pain left her, and sheslept ’1undly. For the next few weeks a certain amount ofosseous 1-tritus and portions of the outer shell were sncces-sively detached, but in about two months’ time the cavity leftby the operation was almost filled up, and the patient dis-charged in a very satisfactory condition.We beg to direct attention to the first of the above cases,

both on account of the peculiarity of the tertiary lesion ofbone, and the good results which attended Mr. Lee’streatment. It is interesting to notice how regularly theiodide of potassium removed the pain; and this fact would gofar to make many surgeons doubt whether this pain dependsreally on distention, for it does not appear very plain howthe iodide could remedy the pressure, except it were in check-ing further secretions. In tension is not the whole secret ofthe pain, and it is extremely likely that the inflammation andmorbid changes going on in the bone, which are both excitedby the presence of the virus, have no small share in the pro-duction of pain. The very small amount of matter evacuated

by means of the trephine, would in some degree strengthenthis supposition.The above-described operations must be looked upon as of

an -xploratory kind; and though the symptoms may havebeen vG,.y obstinate, and have withstood all ordinary remedies,the surgeon is not sure of the condition in which he will findthe parts wmn he introduces his trephine. The most

encouraging circumstance is, however, that were even thepain merely nervous and no abcess found, the patient wouldnot be the worse off for the operation. We must neverthe-less confess, that when we saw Mr. Lee apply the trephine inthe first of the above cases, in which the morbid changes hadtaken place in the head of the tibia, we felt a little appre-hensive as to the fate of the joint, and we are now happy tofind that the articulation did not materially suffer.The second case is especially valuable in a diagnostic point

of view, and proves that considerable alterations may takeplace in a bone situated close to the surface, without theformation of abscess opening externally. Surgeons are so

thoroughly accustomed to see caries and necrosis connectedwith a train of abscesses and subsequent fistulous tracts, thatcases of this kind should be remembered, and aid us in our-dia-gnosis when called upon to treat long-continued pain in bone.

CHARING-CROSS HOSPITAL.

Medullary Tumour of large size, situated in the Right InguinalRegion; Partial Removal; Death; Autopsy.

(Under the care of Mr. HANCOCK.)THE outward characters and intimate structure of tumours

have been of late carefully described, and the labours of suchmen as Milller, Rokitansky, Paget, and others, have certainlyrendered the diagnosis of abnormal growths less difficult thanit formerly was; but in spite of this excellent teaching,tumours are met with in practice, the actual nature of whichit is not easy to determine. Of course the surgeon followsin his investigation the nomenclature and divisions which arecurrent in our times; he first classes the tumour to bediagnosed among the malignant or innocent growths, andafterwards ascertains to which subdivision of the former orthe latter it belongs. But when from outward characters, andthe history of the case, he has thus (with the assistance of amicroscopical examination of the matter deposited on theexploring needle) given it a name, there comes still the ques-tion of removal or non-interference. And this applies both tomalignant and innocent tumours. As to the former, an opera-tion may be forbidden by a variety of circumstances; and somay it be with the latter, for an innocent tumour may be sosituated as to render its removal hazardous; or it may haveattained too large a size to be interfered with; or it may, lastly,have so encroached upon certain organs and cavities, that boththe latter may suffer by an attempt at removal.In the case before us, the ablation of the tumour was

determined upon, as there existed some features whichrendered its malignant nature doubtful, and as it was con-sidered that the growth was lying externally to the abdominalparietes. It will be seen by the following details that boththe external characters and the use of the exploring needlewere well calculated to lead the surgeon astray.John R-, aged twenty-seven, of dark complexion, and

having led an irregular life, was admitted August 8th, 1852,under the care of Mr. Hancock, with a tumour completelyfilling the right inguinal region, and of the size of an adulthead. It appears that about twelve years before admission,the patient first perceived a small tumour, about the size of anut, at about the centre of a line drawn from the anteriorsuperior process of the ilium to the umbilicus. This tumourhe could easily take up with his fingers and thumb, and, as itwere, remove it from the muscular parietes. The patient paidlittle attention to this growth, and for nearly eleven years itincreased almost imperceptibly to about the size of a smallorange. Even at that time the tumour could be moved aboutwithout any difficulty; but from this period to his admissioninto Horsemonger-lane Gaol (whence he was subsequentlyremoved to Charing-cross Hospital), a period of about twelvemonths, the tumour rapidly increased in size, and became asource of great inconvenience, though the patient sufferedlittle or no pain, and allowed the growth to be handled withoutcomplaining.While in prison, he continued in this state for about three

months, enjoying tolerable health, the tumour increasing insize at the rate of about a quarter of an inch in circumferencea month, as evidenced by measurement. The tumour becamenow a source of great annoyance, as it rendered walking diffi-cult, but, with the exception of the extreme tension of theskin, no pain was complained of. The lower portion of thegrowth became every week more pointed, and the wholetumour assumed a somewhat conical form. Towards the lowerportion some fluctuation was now detected, and an exploringneedle was introduced, when about a dessert-spoonful of serumexuded. The upper and outer portions were also tried with

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the needle, but here the parts were more solid, as only a dro{or two of blood escaped.Mr. Wilkinson, surgeon to the prison, to whom we are in.

debted for these details, considered, after this puncturing, thatthe tumour was composed of a number of cysts, that some 01these contained serum, and that the other portions of thetumour were steatomatous. Mr. Wilkinson would have hadno hesitation in extirpating the tumour, had he not been pre-vented by certain prison regulations, as he considered thetumour subcutaneous, and external to the muscular parietes.The patient’s health remained good up to his release from

prison, on which day he was received at Charing-crossHospital.The tumour was then found occupying, as we stated above,

the whole inguinal region, from the crest of the ilium to thepubis; it was larger than an adult head, gave no pain on pres-sure, was elastic and yielding in the lower part, but nodulatedand more resisting in the upper, and large veins were coursingin the integuments covering it. The patient’s countenancewas rather anxious, but his general health seemed pretty good.After he had been a few days in the hospital, Mr. Hancockmade a puncture into the lower part of the tumour with anexploring-needle, and gave exit to a small quantity of serum;the latter was examined by Mr. Canton, and found to containnothing but the usual constituents of that fluid; the exploring-needle being used a second time with the same results, thetumour was looked upon as a multilocular one, and Air. Han-cock, yielding to the request of the patient, consented to re-move it.On the 25th of August the man was placed under the influ-

ence of chloroform, and Mr. Hancock made a longitudinal in-cision through the integuments covering the tumour. Aftera little dissection a tough texture came into view, on dividingwhich a large quantity of clots and fibrinous concretionsarrested the operator. A portion of the internal obliquemuscle was now perceived, and as Mr. Hancock removed theclots and fibrinous masses, he found that he had penetratedinto the abdomen. It now became evident that the tumourwas mainly composed of these soft materials, that it had grownOutwards and inwards, and had destroyed the abdominalparietes. It was therefore thought prudent to carry the ope-ration no further; the lips of the wound were brought togetherby sutures, and the man carried to bed. He rallied prettywell for a few days, but it was evident that the sloughing andpartial haemorrhage which were going on in the groin, were etelling very unfavourably upon his frame. He died about aweek after the operation.On a post-mortem examination, it was ascertained that the

tumour had originated in the walls of the abdomen, and hadtaken, probably at the time it increased rapidly, a directionboth towards the groin and abdominal cavity. The decompo.sition of parts and sloughing were considerable, and the clots,fibrinous masses, and proper substance of the tumour, hadbroken down to such an extent as to leave more a cavitythan a swelling. It was, however, found that the parietes ofthe abdomen had been, in that region, quite destroyed, thatthe tumour lay on the omentum, and was attached to thecsecum and transverse colon. The adhesions were, however,easily broken down; and when these viscera were examinedit was discovered that they were not involved in the disease.No morbid alteration was noticed in any of the larger vesselspassing over the brim of the pelvis, and no tumour or depositwas made out in the principal cavities of the body. Some ofthe substance forming the bulk of the growth was examinedunder the microscope, and found to contain numerous can-cerous cells. IThe deceptive characters which were presented by this 1

tumour were:-lst, the fact of its having originally beenmoveable and distinctly lodged in the subcutaneous tissue;2nd, the very slow development of the growth (except for thelast twelve months), and the almost complete absence of pain;3rd, the serum which escaped upon puncturing the lower por-tion of the tumour; 4th, the excellent state of health which thepatient enjoyed up to the time of the operation; 5th, the non-appearance of that tendency to ulceration which malignanttumours almost always show.Now as to the first of these characters, it may be that the

swelling was originally of a simple kind, but that it took on,at a late period, (when its increase became very rapid,) amalignant nature. The explanation of the second characteris the same as that of the first, though it still remains a verystriking exception, that a medullary tumour should havetaken a rapid development for a twelvemonth, without givingrise to any pain.The serum vhich t’/e mentioned in the third place, was

certainly very puzzling, for the idea of a fibro-cystictumour immediately presented itself, since these tumourshave been known to take their origin from the subcutaneoustissue of the abdomen. But now that we know that thetumour was malignant, it may perhaps be inferred that itsvessels, having become very thin, had given way, that hsemor-rhage had taken place, as happens with the medullarytumours formerly called fungus haematodes, and that theserum obtained had merely separated from the clots.As to the good state of health which we mentioned in the

fourth place, it must be looked upon as an exception, thoughpatients are sometimes met with who do not exhibit the can-cerous cachexia for a long time. Touching the tendency toulceration, which was here absent, (fifth character,) it wouldseem that the pressure, which generally gives rise to it, wasexerted towards the abdomen. The complete destruction ofthe walls of this cavity is certainly a feature which pointsvery strongly to malignancy, but the existence of this destruc-tion could hardly be suspected, as there arose no symp-toms of any abdominal disturbance.

, jM.e mistake not, our readers will rise from the perusalof case with the conviction that the greatest care andattention do not shield from occasional error; and that, as arule, we ought to advocate and advise the early removal oftumours, although they may not create very great inconve-nience. This remark applies to growths both of an innocentand of a malignant kind.

Reviews and Notices of Books.

A Report of the Cctzase Jackson and Wife v. - Roe, Esq., M.D.,as tried at the Devon Slt7mner Assizes, 1852. With Remarks onthe Treatment of Diseases of the Wonzb. By EDWARD T. ROE,M.D., Plymouth. London: Whittaker and Co. Pamphlet,pp. 54.WE briefly alluded to the trial of which this pamphlet gives a

detailed account, at the time of its occurrence. At that period ouropinion, formed from lengthened reports in the local newspapers,was, that the charge against Dr. Roe was most unwarrantableand unfounded. A perusal of the more complete account of thetrial, which is given in the pamphlet before us, serves only tostrengthen that opinion. As is correctly observed by Dr. Roe,-

" The broad outlines of the case for the phintiff are, that

having been told by another medical man she had syphilis, sheapplied to defendant in a feigned name, to know if such was thecase. That during defendant’s attendance upon her, he examinedher, and stated she had also disease of the womb, although shehad never felt pain there."The defendant attended her for eleven months, without her

expressing any dissatisfaction until he sent his hill of twenty-seven guineas—E5 only of which she paid-and she then broughtthis action, affirming she had never told the defendant she hadany other symptoms than pains in the head, face, collar-bone,and arm, and that she never had anything the matter with herbut tic douloureux’ of the face."

It is unnecessary to wade through the mass of disgusting evi-dence adduced for the plaintiff, or to refer even cursorily tothat which was offered on behalf of the defendant. It will besufficient to say that the verdict was justly, in our opinion, givenfor Dr. Roe. There was not a tittle of evidence adduced to

prove the charge of mala-praxis. Would the trial have ever beenheard of, if the demand for payment by Dr. Roe had not beenmade?

Having said so much in defence of Dr. Roe, we should havebeen glad to have thus finished our notice of his production.But the addition which he has made to his report of the trialmust not pass unnoticed. His " Remarks on the Treatment of

Complaints of the Womb" are, in our judgment, most unjustifi-able additions to the report of the trial. The publication of thatproceeding might perhaps have been necessary to vindicate theprofessional reputation of the author in the eyes of the public.Even upon this point, however, a difference of opinion may exist.Surely the full reports which appeared in the local papers weresufficient for the purpose. It could scarcely have been necessary to drag before the public the disgusting narrative 3S"n.Admit that " some professional and private friends" might - desirethat the cause should be published"-can it be pebble that any