ing been decided on, an incision was made through the soft parts to the bone, extending from the margin of the ulcer to the sterno-clavicular articulation. At this point the periosteum was separated and a curved spatula passed posteriorly, and the bone sawed through with Hayes's saw. The periosteum, which was loosely adherent, was peeled off, thereby liberating the bone from its attachments, and it was removed. At the point corresponding with the ulcer the periosteum was destroyed, except a narrow strip about an eighth of an From a Photograph taken on the Day of his Discharge from the Hospital. inch wide, which formed the only connecting medium with the acromion. The arm was retained in position by means of adhesive straps, after Sayre's method for fracture of the clavicle. The patient was discharged cured, August 11, 1874, with a firmly-ossified clavicle, free from dropping of the shoulder or any deformity, and with perfect use of the arm (see Fig. 1). Of recorded cases I have been able to collect the following: CASE I.-M., aged twenty-six years, was admitted into the Hôtel Dieu, Paris, September 7, 1765, with caries of left clavicle. M. Moreau found it denuded of periosteum. The bone was easily isolated (being only retained by the skin) and removed. He died some time after from a tumor of the thigh. On post mortem, the whole clavicle was found regenerated.' CASE II.-M., aged forty years, entered Lariboisière June 27, 1854, for spontaneous fracture of the right clavicle, followed by ostitis and abscess. Resection was performed, with preservation of periosteum and regeneration of the bone. CASE III.—Meyer,' of Zurich, removed a clavicle for caries in a man aged thirty-one years. In seven weeks the wound healed, and the patient recovered the use of the arm. The patient died five years after, and there was found a partial regeneration of bone, the deficiency being supplied by cartilage. CASE IV.-Blondin,' in 1842, resected a portion of the clavicle for caries. He preserved only the periosteum which covered the inferior aspect of the bone. This periosteum reproduced bone, but not a complete clavicle. CASE V.-Biangini, of Pistoja, reports a case of successful extirpation for necrosis. Miguel alleges the bone was regen erated. CASE VI.-John W. Irvine, L. R. C. S., Edinburgh, reports a case of excision and regeneration of the entire clavicle. CASE VII.-Champion' relates that the elder Pelletan ex 1 Chassaignac, "Traité clinique et practique des operationes chirurgicales," tom. i., p. 669. Journal de Graefe et Walther, Bd. xix., p. 71. 'Bull. de la Soc. du Chir., Paris, vol. iv., 2d series, p. 137, 1864. London Lancet, vol. i., p. 206, 1867. tracted the entire clavicle in the case of a child with abscess of the shoulder, following small-pox, and the bone was reproduced. CASE VIII.-Dr. Porquet, of Vire,' removed the right clavicle for caries of both extremities of the bone. In this case there was reproduction of bone. In the "Medical and Surgical History of the War of the Rebellion," part ii., p. 476, Dr. George A. Otis gives the record of thirty cases of extirpation of the clavicle for various causes, in which a number are reported as having successful results, leaving a doubt as to whether the results refer to the recovery of the patients, or regeneration of the part removed; obliging the reader to consult the authorities there quoted for further information.' M. Duplay' reports the following: A young man, sixteen years old, entered St. Antoine March 26, 1872. During the siege of Paris he had variola, followed by an abscess in the right axilla. Abscesses had long since healed. In the beginning of 1873 his right shoulder and axilla became the seat of swelling and pain. An abscess opened in the axilla. The external portion of the clavicle appeared thickened and the tissues infiltrated. An opening was made below, through which there was an abundant discharge of fetid pus. April 4th.-There was found ostitis, and necrosis of the outer portion of the clavicle. August 19th.-Patient etherized, and the periosteum easily raised from the bone, which was divided by a chain-saw at the junction of the middle with the outer third. The outer portion of the bone was then pulled out. Five days after the operation one could certainly feel a hard band giving the sensation of bone. Soon this new bone became as large as the old. In October the wound became fungous and the suppuration more abundant and sanious, and 1 L'Année Médicale, May, 1877. * On inspection of the record above quoted, it will be perceived that but three cases, numbered respectively 10, 24, and 28, reported by Biangini, Irvine, and myself, are noted as having resulted in reproduction of bone. Gaz. Hebdomadaire de Med. et de Chir., Paris, March 6, 1874, p. 155. the new bone became imbedded in the swollen tissues; at the same time the inner fragment became inflamed, and denuded bone was detected with the probe. Nothwithstanding injections of iodine, an abscess formed at the internal extremity of the clavicle. At the end of November the condition of the patient was worse than before any treatment, and he refused to submit to any further operation. This fact shows that the preservation of the periosteum in certain cases does more harm than good. The new bone was of a bad quality, because the periosteum itself was diseased. The health of the patient was perfect at the time of the operation. This case of M. Duplay is certainly an unfortunate one, and carries its own commentary with it; for it is fair to assume that, had the entire bone been removed, a different result might have been attained, and that the unpleasant train of symptoms was due rather to the presence of diseased bone than to unhealthy periosteum. Case of Subperiosteal Resection of the Diaphysis of the Tibia; Regeneration of Bone, and Complete Recovery.—John M., aged nineteen years, a native of the United States, was admitted to St. Francis's Hospital, Jersey City, December 17, 1874, on account of a large indolent ulcer over the centre of the diaphysis of the tibia, covered with flabby granulations, and having for its base denuded and roughened bone. The bone was found to be hypertrophied, particularly at the site of the ulcer, gradually diminishing in diameter both above and below this point. He also suffered severely from osteocopic pains, to such an extent as to require the free administration of anodynes in order to procure sleep. Frequent rigors, followed by fever and sweats, with loss of appetite and emaciation, marked his general hectic condition. His trouble he attributed to "barking his shin" against a cart-wheel, some two years previous to his admission. On consultation with the hospital-staff, it was determined to perform subperiosteal resection, in preference to amputation. I accordingly made an incision over the spine of the tibia, commencing just below the tuberosity, through the centre of the ulcer, to within two inches of the tibio-astragaloid articulation. This incision was carried through the soft parts, including the periosteum, which was found easily separable from the bone. The separation involved the entire circumference of the bone, both above and below, to points at which the periosteum was found firmly adherent, indicating that healthy tissue had been reached. I then passed curved spatula posteriorly at either end of the exposed bone, and made the sections with a metacarpal saw from before backward, sawing down upon the spatulæ, which not only served as retractors, but also protected the soft parts from injury. The entire periosteum, except at the site of the ulcer, was preserved, lying like a trough at the bottom of the wound, and showing completely the form of the posterior and lateral aspects of the bone. The leg was placed in a fracture-box, and the wound filled with balsam of Peru and loosely packed with oakum. Granulations rapidly sprang up from the entire surface of the periosteum, as well as from the cut ends of the bone. Those from the bone assuming a conical form, appearing to spring from the medullary cavity and endosteum, were quite as exuberant from the lower as from the upper portion, reaching out and gradually approximating each other, while coalescing with those from the bottom and lateral portions, soon obliterating the cavity left by the extirpated bone. As the part filled up, the integument was gradually brought together, and finally healed with a very narrow cicatrix, except at the former location of the ulcer, which part did not thoroughly heal until ossification had taken place. The portion removed measured 5 inches anteriorly and 5 inches posteriorly in length, and 5 inches in circumference, as against about 3 inches, the average circumference of healthy bone. The part removed, on longitudinal section, was found to be eburnated to nearly its entire thickness, which, taken in connection with its hypertrophied condition, would indicate the existence of chronic ostitis. The structural changes are shown in the accompanying cut, which represents the actual size of the part removed (see Fig. 2). Solidification progressed rapidly, and at the end of six months |