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Three X-ray photographs taken from a series which show the gradual decrease of fluid in the pericardium. A, taken on Pec. 27th. Threedays later 1000 c.cm. of fluid were removed from the pericardial sac. On Jan. 6th 20M c.cm. of fluid were removed. B, taken on-Feb. 15th, three days before aspiration, when 1600 c.cm. of fluid were removed from the pericardial sac. C, showing condition thefollowinly dav (Feb. 19th).

Further aspirations of the pericardial sac were carried outin conformity with the condition revealed by X ray examina-tion, the patient developing an increasing tolerance, bothconstitutionally and symptomatically, to the presence of avery large reaccumulation of nuid. On Jan. 6th, 1919,2050 c.cm. were removed. The fluid was darker in colour.No clots. On Jan. 31st over 1000 c.cm. were removel. OnFeb. 18th, although the patient exhibited no symptoms ofdistress, X ray examination revealed a large reaccumulationof fluid-1600 c.cm. were removed. The fluid contained asmall number of polynuclear cells, but was sterile.At the time of the first aspiration there was distinct

oedema of the front of the chest wall, but this did not recurto any extent as the pericardial sac refilled. For the first10 days or so after admission to hospital there was a con-siderable amount of fever, ranging from 99° to 103°, but forthe last few weeks the temperature chart has shown a

subfebrile condition with occasional short rises. In view ofthe gravity of this case it is remarkable that the pleural andpericardial cavities alone showed any evidence of disease.At the present time (Feb. 25th, 1919) the patient is in fairgeneral health. Although a little dyspnceio there is noorthopnoea and the pulse is perfectly regular, as shown bypolygraphic tracing.We consider both the pleural and pericardial inflammation

in this patient to be the result of infection of thesemembranes with tubercle. The cytological picture pre-sented by the predominating lymphocyte count, coupledwith the uniform sterility of both pleural and pericardialexudates on ordinary media, clearly point to this conclusion.The special features in this case are the extreme distensionof the pericardial sac and the large quantities of fluidremoved by aspiration, the marked relief afforded by theearly aspirations, and the remarkable tolerance shown in thelater stages to the presence of very large reaccumulations offluid.

COMMINUTED FRACTURE OF HUMERUS.

BY WINIFRED F. BUCKLEY, M.R.C.S.,SURGEON, ENDELL-STREET MILITARY HOSPITAL, LONDON, W.C.

f(THE following is a case of comminuted fracture of the p

humerus from the upper end of the shaft to the elbow, c

which healed and united firmly without the formation of I

sequestra. -

n

Pte. -, wounded on April 22nd, 1918. The bullet entered g,the upper surface of the right shoulder and passed longi- g,tudinally down the shaft of the humerus ; wound of exit irover right elbow. He was operated on at the C.C.S.;admitted to the Military Hospital, Endell-street, three days =later. On admission there was a clean sutured wound onthe inner side of the arm about 6 in. long, a small super-

Cficial wound the size of a shilling over the head of the Uhumerus, and a wound on the outer side of the elbow-joint a:

leading into the joint. Much swelling and oedema of the tl

whole arm, forearm, and hand. X ray showed severe

comminution of humerus from the elbow to upper endof shaft, with fracture of the olecranon and capitel-lum of radius. (Seefigure.)

I treated the fracturefirst on a broadinternal angular splintpassing up above theshoulder-j oint,and fixedto a counterpoise foreight weeks, then withan aluminium splintand Gooch splint-ing. There was veryslight discharge ofpus from the elbow-joint for some weeks.The wounds healedwith very littletrouble, they were

treated with bipp,and the dressingschanged about once

a fortnight underan anaesthetic. Themusculo-spiral nerve

was completelysevered, and was

sutured four monthsafter the injury.The remarkable fact

is that the wholeshaft united firmlyin good line withoutthe formation of a

single e sequestrum.Probably the bulletpassed verticallythrough the shaft ofthe humerus, break-ing it into smallpieces without sepa-rating the periosteum.The elbow is anky-losed. Power in thefingers and wrist isfairly good, exceptfor the muscles sup-plied by the mus-

culo-spiral nerve.

There is a good move-ment of the shoulder.The oedema was per- Comminuted fracture of the humerus.

6115tuLtul tuum um .LHJtJ

subside for three months. The fragments had united firmlyin 14 weeks.

DORSET MENTAL HoSPITAL.-The Dorset CountyCouncil has decided to change the name of the countyasylum to that of the Dorset Mental Hospital. At presentthere are 442 male and 602 female patients in the institution.