A METHOD OF TREATING FRACTURE OF THE CLAVICLE

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    ostium, the ovary and mesosalpinx being normal. There wasno sign of actinomycosis in the left appendages, either on Jmacroscopic or on microscopic examination. The rightappendages also showed a thickened and indurated Fallopiantube attached to the broad ligament which was infiltratedwith soft friable tissue from which a solid tumour represent-ing the ovary had become detached. This separate tumourconsisted of an irregularly ovoid solid mass with a tuberose iand in places worm-eaten-like surface. It was of a uniformly fgreyish-yellow colour and measured, after hardening in 1formalin, 2! by 2 by 3 inches, being 10 inches in circum- iference. It weighed 7 ounces. On cutting across the amass uniform yellow pus was seen to exude from numerouspoints, the cut section presenting a regular honeycomb-like structure, while towards one pole of the tumour va larger abscess cavity of about the size of a walnutwas present. Nodules characteristic of actinomycotic Ipus were not observed with the naked eye. Films of the puswere made and stained with methylene blue and degeneratepus cells and granular detritus were seen but no micro-organisms of any sort. Agar tubes were also inoculatedwith the pus and incubated at 370 0. but remained sterile.A portion was excised for microscopic examination and the

    tumour was then hardened whole in formalin solution.Sections were stained with hsematoxylin and eosin. The ovarywas transformed into a mass of loose connective tissue withmarked small, round-celled infiltration, scattered irregularlythroughout which were small foci of suppuration. No traceof ovarian structure was left. The cellular infiltration of theconnective-tissue stroma consisted mainly of lymphocytes.A few giant cells were observed scattered through theconnective tissue, but these were not surrounded byzones of epithelioid cells and lymphocytes as in typicaltubercles. The giant cells were multinuclear, the nucleibeing massed around the periphery of the cells, and in someof the nuclei typical somatic mitotes could be seen.

    Further sections were subsequently taken from less degene-rate parts of the tumour and stained for bacillus tuberculosisby the Ziehl-Neelsens method, but this organism was notfound, nor did the streptothrical mycelium retain the red colourof the carbol-fuchsin, which showed that it was not an acid-fast streptothrix. Sections were also stained by Grams methodand counter-stained with eosin. The scattered purulentcollections were well seen by this method as pink areas,throughout which small masses of a streptothrix retainingGrams stain were found. These masses were composed of aclose felt-work of mycelium in which the filaments weresomewhat granular in appearance, their structure being bestseen at the periphery of the mycelial masses. No club formswere observed. These appearances are all typical of sectionsof actinomycosis as affecting human tissues.The source of the streptothrix and its mode of ingress to

    the body must in our case remain somewhat doubtful.Except for rare and brief holidays the patient had lived inLondon as cook in doctors families for the last 16 years andprior to that time was at school in Bristol, but was broughtinto contact with hay, straw, and corn, the usual sources ofactinomycosis, in 1903 and 1904, when the house in whichshe was engaged had a stable near the back door, the patientgoing into the stable regularly three or four times a day tofetch fuel and sometimes to feed the horse. We maypossibly here find the explanation as to how the disease wascontracted, since the symptoms date from 1904.

    Since the ovary occupies a secluded position in the closedabdominal cavity, it can only be infected either by the directextension of disease from an affected contiguous organ or bythe blood-stream. As in this case there was no evidence ofdisease in any adjacent organ the streptothrix must havereached the ovary by way of the blood-stream, the mode ofentry into the body being, we suggest, some cryptogenicfocus-e.g., the tonsil, through which it is well knownmicro-organisms may pass into the blood-stream withoutproducing any local lesion. It may further be pointed outthat the ovary provides a peculiarly fertile soil for thegrowth of infective micro-organisms and of detachedcarcinoma cells, as evidenced by the frequent occurrenceof large ovarian growths secondary to mammary and intes-tinal carcinomata. It can thus be readily understood thatthe streptothrix may have been deposited in the ovary by theblood-stream and so have given rise to a primary ovarianactinomycosis.We are indebted to the kindness of Dr, Fenton for per-

    Plission to publish this case,

    A METHOD OF TREATING FRACTURE OFTHE CLAVICLE.

    BY FRANK ROMER, M.R.C.S. ENG., L.R.C.P. LOND.

    I HAVE had the opportunity of treating a number offractures of the clavicle by a method which has given mesuch satisfactory results that I venture to draw attention tothe advantages which it possesses. A brief description of theinjury may serve to illustrate the raison dtre of the methodadvocated.The usual condition, when the injury has been caused by

    indirect violence, is for the inner fragment to be kept inposition by the rhomboid ligament so as to cause aprominence at the seat of fracture, the outer being displaceddownwards and inwards, whilst the shoulder drops forwardsand downwards. This displacement is caused by the actionof the serratus magnus and pectoralis minor muscles, un-restrained by the stay of a sound clavicle, drawing the scapulaforwards, and is not, as frequently stated, due to the weightof the upper extremity. This can be shown by the fact thatmerely supporting the arm so as to remove the weight causesno alteration in the deformity. On the other hand, if theshoulder be drawn back or the patient laid flat on his back,so that the scapula is pushed backwards reduction is effected.From this it appears that the best way of keeping thefragments in good position and preventing the return of thedeformity is to render as far as possible the scapulaimmobile.

    In the method which I employ, therefore, no attempt ismade to confine the arm to the side, and, once the scapulais fixed, the movements of the arm need no more restrictionthan can be obtained by an ordinary sling. The techniqueof the method is thus described: "Three strips of firmadhesive plaster, each an inch and a half in width, should beapplied, from a point immediately above the nipple to apoint below the angle of the scapula. The middle stripshould cover the seat of the fracture and should be first

    applied ; the lateral ones, slightly overlapping it, shouldextend about an inch and a half on either side. Each strip

    . should first be made to adhere strongly in front, and, whileLit is supported and fixed by the fingers of one hand, should

    , be carried over the shoulder by the other, with steadypressure, and made to adhere as it goes." In addition toL these strips I have found it advisable to apply another which; encircles the shoulder-joint, one end being brought diagonallyt across the scapula to below its angle. To prevent chafing orthe plaster adhering to the hairs a thin layer of wool should3 be placed in the axilla. The strapping once applied, the

    patient can dress in the ordinary way, the arm of the injured) side being supported by a sling.. For the first two days use of the arm should be restrictedi to underhand movements, though one rarely finds much1 desire on the part of a patient to do more. As soon ast possible the services of a skilled rubber should be obtainedf and the injured parts daily massaged for at least a week. I1 should mention that the rubbing can be effectively performedt over the plaster. At the end of this time the sling can3 usually be discarded and the patient can be safely en-ycouraged to take the arm into more general use. Thes strapping should be renewed at the end of the first four days

    and again from time to time as occasion demands. By thed end of a fortnight all movements are as a rule possible, but;t the lifting of heavy weights should be avoided. The partsy should be kept supported by strapping for at least threeIf weeks, even though no pain be experienced on movement.e I quote the following cases :-f CASE l. -A man, a flat-race jockey, fell during a race andc fractured his right clavicle. He was attended to on then course and the fracture was put up in the orthodox method..t He was seen by me on the day of the accident and the.t shoulder was strapped and rubbing was ordered. Hee kept his arm in a sling for ten days. He rode and won ad race 17 days after the injury without ill effects, but he hade some pain as the horse I I yawed " at the post. The shoulder!- was strapped once afterwards but he continued to ride,t regularly.e CASE 2.-The patient, a flat-race jockey, sustained an complete fracture of the left clavicle through the fall

    of his horse in a race. He was seen six days afterc- treatment by the orthodox method. He was in consider-able pain and distortion was still present at the junction of

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    the middle and outer thirds. The bandages were removed,the fracture was strapped, and rubbing was ordered. Twodays later the pain had entirely gone. The arm could bemoved comfortably. Within 20 days he was able to ridegallops and rode in races a week later.CASE 3.-A flat-race jockey fractured his left clavicle in a

    race and was attended to on the course. When seen on theday of the accident the bandages had slipped and the manwas in great pain. Strapping was applied and rubbing wasordered, which speedily relieved the pain. The fracture wasre-strapped in threedays. Uneventful recovery followed andthe patient was riding within three weeks from the date ofthe injury.CASE 4.-A man fell while hunting and fractured the

    right clavicle; the displacement was slight. The shoulderwas strapped and rubbing was ordered. The patient wenthunting contrary to advice two days after the accident andcontinued to hunt throughout the treatment. There were noill effects though the resulting callus was considerable. Hecomplained of no pain after the first 12 hours following theinjury.CASE 5.-A man fell whilst riding in a steeplechase and

    fractured the right clavicle which was put up at a neighbour-ing infirmary in the orthodox method. When seen on theday following the accident the right hand and forearm wereswollen and painful, and there was a large amount ofswelling and bruising over the seat of the fracture. Thetemperature was slightly raised. The fracture was com-minuted. He was advised to rest in bed flat on his back fora few days. The bandages being removed, the shoulder wasstrapped and rubbing was ordered. The pain in the fore-arm disappeared after the first rubbing. The swelling at thefracture gradually subsided and he was up and about in aweeks time. He was practically sound within three weeksbut did not ride steeplechases for a month.CASE 6.-A flat-race jockey sustained a complete fracture

    of the right clavicle through his horse falling dead during arace. He was treated in the orthodox method on the course.When seen on the day after the accident he complained ofgreat pain in the hand and forearm. The bandages wereremoved, strapping was applied, and rubbing was ordered.He made a quick recovery and was riding within 18 days ofthe accident.

    CASE 7.-A flat-race jockey fell in a race and fracturedhis right clavicle. This boy had fractured the same claviclesome few months previously. When seen on the day afterthe accident there was considerable swelling over thefracture, and the patient was obviously shaken by his fall.Rest in bed for two days with massage was ordered, theshoulder being fixed by strapping. He was race-ridingwithin three weeks of the injury.CASE 8.-A steeplechase jockey fell in a hurdle race and

    fractured his right clavicle. He was attended to on thecourse. When seen on the day of the accident there were acomminuted fracture which caused great pain and a lump onthe forehead. The man was dazed and vomited in the con-sulting-room. He was kept flat on his back for five days,the fracture being strapped and rubbed as usual. Morphine,i gr., and calomel, 1 gr., were ordered. At the end of aweek, the effects of the concussion having passed off, thepatient was allowed to get about as usual. He made anuneventful recovery, though the risk of falling prevented mepermitting his racing for a month.CASE 9.-A steeplechase jockey fractured his left clavicle

    during a race. When seen on the day of the accident thedisplacement was very marked at the junction of the innerand middle third. Treatment was by strapping and rubbing.He won a hurdle race within 14 days of the injury and con-tinued riding as before.CASE 10.-A flat-race apprentice jockey fell and fractured

    his clavicle, which was put up in the orthodox method on thecourse. When seen on the day after the accident the fracturewas severe, with much bruising, and caused considerable pain.The patient was kept on his back for two days and treatmentwas as usual. Twenty-three days from the date of theaccident I received a letter from his master saying that theboy was apparently sound and had been riding as usual. i

    I have selected those cases the after-history of which I Ihave been able to watch. The quick recovery which the ,majority have made is partly due to the healthy lifeled by the injured. The strain on both shoulders in ridingraces or fast gallops is very severe and it is for that reason I ;

    take race riding " as a test of soundness. The advantagesto be obtained by treating these cases in this way are:Firstly, freedom from the pain caused by keeping the armand forearm rigid. This is most noticeable where the patienthas already spent some hours trussed in the orthodox position,the relief of pain on freeing the arm being almost immediate.Secondly, the patient is enabled to dress normally and canuse the arm of the injured side for writing, and feeding,without fear of harm. Thirdly, in consequence of the armbeing in use, the muscle wasting is comparatively slight andis fit for ordinary strains once union is complete. Fourthly,the period of disability in general is considerably less thanin cases treated on more orthodox lines.The method to the description of which this paper is de-

    voted is due to Dr. Wharton P. Hood who describes it in hisbook on the "Treatment of Injuries."

    Seymour-street, W.

    A CASE OF OLIGOHYDRAMNIOS WITHPARTIAL AMPUTATION OF A FOOT

    OCCURRING IN A UTERUSUNICORNIS.

    BY LEONARD C. BLACKSTONE, L.R.C.P. LOND.,M.R.C.S. ENG.,

    LATE RESIDENT MEDICAL OFFICER TO OUT-PATIENTS AT QUEENCHARLOTTES LYING-IN HOSPITAL, LONDON.

    A WOMAN, aged 30 years, gave birth to a premature femalechild (16 inches long) in October, 1908. Labour was com-plete in two and a half hours. The patient stated that shelost no I I waters " either before or with the birth of the child.The midwife, who arrived a few minutes after the child wasborn, found the bed dry. The childs left foot was swollenand cedematous and a tough fibrous band was found twistedtwice round the leg three-quarters of an inch above the ankle.On the removal of the constricting band the skin was foundto be divided round the whole circumference of the leg. Thechild was able to flex and to extend the foot and toes, provingthe tendons, &c., to be undivided. There were no congenitaldeformities ; the skin was normal and no renal or cardiacaffections could be detected. The cedema of the foot hadcompletely disappeared ten days after birth and the skinlesion healed. The child died three weeks after birth frommarasmus.

    The third stage of labour lasted half an hour. The maternalsurface of the placenta was ragged and torn ; the whole ofthe chorion and the greater part of the amnion were retained.A tough amniotic adhesion stretched from a point on thefunis two inches from the placental end to be attached to thefoetal surface of the placenta three inches from the insertionof the cord. This band was four and a half inches long andvaried in breadth from one inch at the funic attachment tohalf an inch at the placental attachment. From the sameposition on the cord another band ran to join the amnionclose to its junction with the placenta. This was nine inchesin length and four inches broad at its outer attachment. Thetough cord-like adhesion removed from the childs leg wassix inches long and one-sixteenth of an inch in diameter.Ergot was prescribed and the retained membranes wereexpelled with the lochia on the third day. They were un-fortunately destroyed without examination. The lying-inperiod was normal.The previous obstetrical history of the patient is interest-

    ing. Her first child, now five years old, presented by theface, but was born without any operative interference.Seven months later the patient was operated on by Mr. AlbanDoran at the Samaritan Hospital for a ruptured cornualgestation ; the right cornu and appendages were removed.This case was published in the Jovrnal of Obstetrics and6ynaeoology in June, 1906, by Mr. Doran. One year later thewoman gave birth to another child, presented by vertex. Inthis confinement there was some delay in the third stage.After a further 18 months the patient had anotherchild ; this presented by the breech. In this case the thirdstage lasted over two hours and part of the membranes wasretained. The patient had developed a ventral hernia in theupper part of the abdominal scar. The hernial apertureafter her last confinement easily admitted the hand andmade palpation of the uterus extremely easy. The asymmetry

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