Mrs. F., aged 70 years, was found in the yard attached to her house in a prostrate and semi-comatose state, at seven o'clock on Tuesday morning, April 14, 1885. She was aroused with difficulty, and when spoken to answered incoherently, saying that she became dizzy and fell. Assistance was obtained, and she was taken to the house, and, finally, to bed. She rapidly became more and more comatose, and later in the day, when I was called in, she was fully unconscious. I tried to get her to swallow but without avail, even when water was dropped on the back of the tongue, she made no effort to swallow. She vomited frequently during the first day and night. Pulse was round and full, but very feeble and slow the first day, and gradually increased in frequency and decreased in volume until the sixth and seventh days, when it became very small and feeble, so much so that it could scarcely be felt at all. Respiration was labored and but slightly stertorous and exaggerated. Mouth wide open and nostrils dilated. Temperature elevated and varied, being higher in the right axilla at first, and finally lower, as can be seen in the following table, which I deem very interesting as showing the changes of temperature that took place in regard to both axilla : TEMPERATURE. Eighth, 4 P.M., died; one hundred and seventy-seven hours from the time she was found in the yard. The right side was paralyzed; the face and tongue were drawn to the left. Although there was complete muscular relaxation, feeble movements could be excited during the first and second days. Free perspiration and a free action of the kidneys were present. Urine passed involuntarily in large quantities. Both pupils were minutely contracted, and her eyes were deeply injected. Severe conjunctivitis developed on the third day. An autopsy was asked for, but refused. PENN, PA. HOSPITAL REPORTS. CHARING CROSS HOSPITAL. UNDER MR. J. ASTLEY BLOXAM, F.R.C.S. Displacement of the Tibia on Right Side, Outwards and Backwards, as Result of Disease.-Margaret C-, age 16, was admitted on January 24th with the following history: Nine years ago she fell down stairs, but did not call attention to it, and it was only when her leg began to swell that her mother noticed it. Six months later, the leg continuing bad, she was taken to Kings College Hospital, where she remained under treatment two months; when she left the hospital her leg was straight but she was unable to walk without crutches. She gradually, however, recovered strength in the limb to some extent, but in trying to dispense with the crutches the right leg became bent, and this increased as time went on, but she had no further advice. Patient was born and brought up in London, and says she has always had sufficient food and clothing. Her brothers and sisters are healthy. She has not yet menstruated. On taking measurements, the distance from the head of the fibula to the external malleolus, on the right side was twelve and a half inches, and on the left sixteen inches. From the internal malleolus to the tip of the big toe, right side seven inches, left side seven and three-quarters inches, while from the anterior superior spine of ilium to sole of foot, right side thirty-three and a half inches, left side thirty-seven inches. The right leg was of less size generally. The patella is fixed on the right side, and the tibia is displaced outwards and backwards, and the inner hamstrings are very tense. Patient can flex her leg to a little | Previously.-Edward S-, aged 34, laborer, beyond a right angle, and can extend it to an was admitted on November 7th. He had angle of ninety degrees. There is no fluctua- gonorrhoea when sixteen years of age, which tion, and very little pain. Temperature nor- was cured, and on one occasion a stoppage of mal. On February 7th, patient being under the water was relieved by the passage of a the influence of ether, Mr. Bloxam made small stone. Three years later he contracted a small incision just along the external border a second attack of gonorrhoea in China. Eighof the patella, when he found it was firmly ad- teen months afterwards he was in the hospital herent to the external condyle of the femur, for three months with pain in the region of kidbut after a little trouble it was shifted, and an neys, relieved when vomiting was induced. attempt was made to straighten the leg, but In 1877 he went into the hospital at Montreal, this did not succeed, owing, it was thought, to on account of a difficulty in passing water, the contraction of the hamstring tendons, so when, on examination, a stone was detected in tenotomy was performed, and another attempt his bladder. He was operated on, and a stone made to put the leg straight, but again did not about the size of a walnut removed. He resucceed. Mr. Bloxam then continued his ex- turned home in December of that year and then ternal incision, converting it into a semilunar drank freely. He noticed that he was unable incision and excised the knee-joint, afterwards to hold his water more than a short time, and wiring the tibia and femur together with metal on passing it, felt a pain in the urethra and at sutures. The wound was then sewn up with end of penis. He has a penile fistula, which horsehair and drainage tubes put in, the whole was left after the operation, and water often operation being performed under strictly anti- escapes by that aperture, preceded by a yelseptic precautions, and an antiseptic dressing low discharge. 9th-Examined under ether, applied. In the evening recurrent hemorrhage a stone was discovered impacted in the urethra, set in, and Mr. Bloxam had to be sent for, a which on removal was seen to be about the size of tourniquet was placed on the common femoral a small bean. A stricture which was situated artery, and ice-bags applied to the knee. Some behind the stone was divided and a No. 9 silver six ounces of blood escaped. The dressings catheter left in. Evening temperature 101.4° were then reapplied, and an ordinary T-shaped Fahr. 11th-Carbolic acid dressing was apsplint. Temperature next morning 101° Fahr. plied this morning. The silver catheter came Pulse 120. 9th. The dressings were removed out in the evening, and was replaced by a No. again to-day, and some blood was still present. 6 gutta percha. There is not much discharge, 11th-Temperature this morning 102.6° Fahr.; and the wound appears to be healing rapidly. tepid sponging ordered. Patient complained Temperature 100.8° Fahr. 13th-Patient of a good deal of pain in site of operation. complains of feeling thirsty, but he has slept 12th-Pain is less, and the temperature is now well. His urine contains a small quantity of 99° Fahr. Patient looks brighter. 15th- albumen. Temperature 102.4° Fahr. The Temperature 100.2°; the wound was redressed abscess increased rapidly in size since yesterday, this. afternoon and some of the stitches re- and to-day discharged a considerable quantity moved. There is a good deal of discharge of sanious pus. 14th-He complains of great from the wound and some slight pain. Tongue pain in the hypogastric lumbar regions, and ocis furred with red papillæ. 19th-To-day casionally in the back. The abscess is still disMr. Bloxam fixed the leg in position by means charging freely, and there is some scalding on of bags of plaster of Paris. The drainage-tubes micturition since the catheter was removed. were discontinued. The leg feels more com- His urine has specific gravity 1010, alkaline, fortable. 25th-The wound was redressed and contains mucus and pus. 15th-The payesterday afternoon, and a pad of lint was tient was anesthetized this morning, and a silver, placed under the heel. The wound looked No. 9, catheter introduced. He felt much quite healthy and sweet. Temperature 100° better after this was done, the pain and tenderFahr.; pulse 116. March 8th-The wound ness being much less. 21st-He has been is now almost completely healed. Patient was much better the last few days, and has no pain discharged on the 15th. whatever. No urine passes from the wound, Urethral Calculus; Stricture of the Urethra and the catheter has remained in. 29th-The Posteriorly; Lithotomy Performed Five Years | patient complains of pains between the buttocks. The urine is quite clear and the wound dis- and his hands are tremulous. He was ordered charges a small quantity of healthy pus. mxv of liquor opii sedativus night and morn The wound ultimately healed up and the pa- ing. 7th-The antiseptic dressing was changed tient was discharged on December 15th. to-day. Several large bullæ had formed over Sloughing of Dorsum of Foot after Injury. the surface of the leg, which were opened. -Benjamin S—, aged 42, packer, was injured Mr. Bloxam saw the patient in the afternoon, ten days ago by a packing case falling on his and, as the limb was very tense and oedematous, foot. He took no notice of it at the time, but he made six or eight incisions into it. The about a week later he could not get his boot on patient did not seem to notice any pain, and because of the swelling. He applied to his appeared drowsy. Temperature 101.4° Fahr. club doctor, who at first told him to poultice 8th-A slough formed in the wound, and was it, and subsequently cut into it and evacuated removed, exposing the lower end of the upper a quantity of pus. From this incision the skin fragment. The patient seems a trifle better togradually sloughed away and spread until, at day and answers questions. Temperature present (March 12th), the whole of the outer 102.6°. 9th-The patient is very weak, and side of the left foot is covered with blackish a large triangular slough was formed around sloughs mixed with pus. There is an aperture the original wound, which is dressed with warm in the lower and outer part of the foot filled carbolized gauze every four hours. Temperawith necrosed tissue. The foot was washed ture 101.8° Fahr.; pulse 138; respiration 40. with warm boracic lotion, and as much as pos- 10th-On removing the slough, the seat of the sible of the sloughs removed. 14th-The sur- fracture became visible. It extended right face from which the skin has sloughed is granu- across at the junction with the lower third, and lating, and the process does not appear to be a large fragment was splinted off the inner side spreading further. The patient looks well and of the upper fragment. The cavity was syringed has a good appetite. 20th-The patient's gen-out with carbolized water and the dressing reeral condition continues good and he sleeps applied. 11th-A large slough is forming on well. The granulation is going on satisfac- the outer side of the ankle; the patient is evitorily. 26th-This morning his temperature dently sinking and is very weak. His breathwent up to 103.5° Fahr., and he looked flushed. ing is at times quite stertorous. 12th-The He perspired freely, and his urine was scanty slough over the ankle was opened and a large and thick. 28th-The temperature is still amount of discharge set free. A similar slough high, and red lines are visible in the course of is beginning to form on the inner side of the the lymphatics on the outer side of the limb. ankle. The pulse is almost imperceptible. Patient is thirsty, but says he feels well other-13th-The toes were quite cold this morning wise. April 1st-Patient died to-day from ex- and of a purple color. The leg was removed haustion. from the splint and wrapped in wadding. The tongue was covered with a thick brown fur, and sordes are forming on lips and teeth. The patient died at 3 P.M. At the post mortem examination the fibula was found to be fractured in two places, above, two inches below the head-comminuted; and below, about an inch above the malleolus, also extensively comminuted. The fracture of the tibia has already been described. There were no signs of pyamia, death being apparently due to exhaustion from the injury, intensified by the delirium tremens. Compound Comminuted Fracture of Lower Third of Left Tibia and Fibula; Delirium Tremens; Extensive Sloughing of Wound; Death. Henry A—, aged 40, potman, was admitted on November 4th, having fallen down stairs. He was found to have a compound comminuted fracture of the tibia and fibula at their junction with the lower third. The upper fragment protruded about an inch and a half through a wound the size of a shilling. The displacement was remedied, and the limb put up on a back and side splints, the wound being dressed antiseptically. 5th-The dressing was Ankylosis of Knee Joint; Forcible Flexion. changed this morning, his temperature last-Sarah W-, aged 33, married, was admitted evening was 99.4° Fahr.; pulse 132. Patient on the 10th of September with the following is very tremulous, excited and nervous. He history: Eight years ago she suffered from inwanders rather in talking, but will answer sen- flammation of the bursa patellæ of both knees, sibly when questioned. His tongue is furred the right knee however recovered. Some time after she fell down stairs, straining her left some oedema of scalp, and the patient appears knee, which was still imperfectly recovered drowsy. 30th-The swelling is very much. from the previous inflammation. The injury less to-day, but patient complains of feeling ill was treated by a doctor at the time, but ever all over. He has some tightness in breathing, since the joint has been growing larger, and is and at times can scarcely speak. Temperature both painful and tender. When she stands 100.6°. Pulse 95; hard and firm. April 8th upon it, it rapidly swells even more than at-Patient has now recovered from his attack of present. At first she was able to move her leg | erysipelas. A central incisor was removed toeasily, but the power was gradually lost, and day, as it was lying loose in the fracture at the now only very slight movement is possible symphysis, and prevented the fragments uniting. either way, the ordinary position being one of 20th-The swelling at the angle of the jaw has slight flexion. been increasing in size, and yesterday a large quantity of pus was evacuated. Patient is very hoarse to-day, but a slight congestive condition of the fauces and palate was all that could be seen. 27th-Poultices are being applied to the incisions at the angle of the jaw, and there is a good deal of discharge. Endeavors have been made to secure apposition of the fragments by wiring the teeth, but no satisfactory result was obtained. The gutta percha splint was reapplied. May 8th-The teeth have been secured together by means of a fine cord, and the fragments appear inclined to unite. 10th-He was made an outpatient to-day, as matters seem to be going on all right, and there is every hope After a day or two of rest in bed the swelling went down, but the joint is very hot and tender. The patient was placed under chloroform and the leg forcibly extended. This proceeding was followed by a good deal of pain and swelling of the joint. 26th-The knee is still swollen and very tender, the slightest movement causing considerable pain; the joint was therefore wrapped in cotton-wool and a plasterof-Paris bandage applied. 28th-No pain at present except on being moved; patient is able to get up for an hour or two in the afternoon. 30th-Passive movement is to be carefully resorted to every day. October 10th-The patient was discharged with a very fair amount of move-of proper union. This patient subsequently ment in the joint, which was free from pain. Case of Comminuted Fracture of the Lower Jaw.-John P-—, aged 42, cab driver, fell off his cab about five weeks ago, and the wheel passed over the left side of his face, obliquely, fracturing the lower jaw in two or three places. It was set in the accident room, and he attended regularly for some weeks, but, as it did not apappear to be progressing satisfactorily, he was admitted into the hospital on March 17th. There is a good deal of swelling on the right side, and beneath the chin fluctuation appeared to be perceptible. The patient's breath is very offensive. 21st-A small incision under the The chin, made this morning, allowed a small quan- made a good recovery, with perfect union. M. Sig. Give to children between six and eighteen months' old from ten to twenty minims after every paroxysm of vomiting, and every hour or two during the acute serous diarrhoeal stage. The important clinical fact must be remembered, that in all cases of copious intestinal evacuations, the urine is liable to become scanty, and that the suppression of such evacuations by opium and astringents often exerts an unfavorable influence upon the function of the kidneys, resulting in more or less complete suppression of the urinary secretions. This complication can be avoided by the following combination: Mix and add to one part of boiling water to make an infusion. When it is cold, give one teaspoonful every four hours to a child one year old. This combination has the advantage of being diuretic and tonic, as well as anodyne and astringent. In protracted cases, accompanied by marked anæmia, excellent results may be obtained from suitable doses of the liquor ferri nitratis after meals and the administration of one of the following powders at bedtime : B. Pulv. opii. Quiniæ tannatis . M. Ft. charta No. vi. M. Sig. One teaspoonful in water every hour. M. Sig. Teaspoonful every hour and a half. M. Sig. Half teaspoonful every three hours. |