541

man was in much less pain. The slough separated a fewdays later, and the patient when the report was made wasin the hospital with a healthy ulcer, healing.CASE 3.-Charles J-, aged thirty-eight, an ironworker,

living at Hampton, was admitted into Grosvenor ward onJuly 7th, under the care of Mr. Pollock. Two years ago henoticed a swelling over the left knee; eight weeks ago theskin gave way, and one week ago the ulceration began tospread. He had had rupial ulceration some years before.On admission, there was an inflamed ulcer, about fourinches in diameter, over the left knee; the edges sharp,cut, and everted; slough almost entirely separated; nuzne-rous rupial scars about arms and body. He was ordered

ordinary diet, one pint of porter, tin minims of tincture ofopium, with fifteen grains of chlorate of potash, quinine andiron. On July 10th the opium was replaced by five grainsof iodide of potassium. The ulcer rapidly assumed a healthycharacter, and is now fast healing.CASE 4.-Nicholas L-, aged thirty-five, a labourer,

living in Marlborough-road, Chelsea, was admitted intoGrosvenor ward on July 16th, under the care of Mr. Pollock.Five weeks before, after connexion, he noticed a sore onpenis. Three weeks ago it commenced to spread, and toslough. He had had syphilis twelve years previously. Onadmission, there was a large sloughing sore round the baseof glans penis; edges everted, and sloughing extending.He was ordered ordinary diet and one pint of porter; iodideof potassium, ten grains; water, three ounces: three timesa day; compound ipecacuanha powder, ten grains, everynight. For a few days the sloughing did not seem to spread,and a tubercular eruption broke out on his face; half adrachm of mercurial ointment was rubbed in every night.The sloughing again extended, and rupial sores broke outon various parts. He was ordered one drachm of opiumand half a pint of water for a lotion; citrate of iron, tengrains; iodide of potassium, ten grains; water, one ounce: three times a day; opium, one grain, every four hours. Itcontinued to spread for about ten days, and then stopped,after having destroyed the greater part of the skin of thepenis and a portion of that of the scrotum. The wound isnow quite healthy.CASE 5.-Henry H-, aged fifty, lately living in Chelsea,

was admitted on August 4th, under the care of Mr. Pollock.Had syphilis thirty-five years ago, twelve years previouslyrupia, and one week ago a pimple formed on the inner sideof the left leg; skin gave way, and an ulcer rapidly spread.On admission, there were rupial scars about the face, nose,and legs. There was a sloughing ulcer, the size of a child’shand, on the inner side of the left leg; edges everted, andsloughing extending. He was pale, and looked much older.Ordered ordinary diet, and a pint of porter; iodide of potas-sium, ten grains; tincture of opium, fifteen minims; chlorateof potash, twenty grains; a draught of quinine and ironevery six hours; six ounces of port wine daily. On’Aug. 6ththe sloughing had ceased, and slough beginning to comeaway. The wound is now quite healthy.

Since the preceding was written, one other case has beenadmitted; but no wound in the hospital took on an un-healthy form from its admission, though it was placed iiia ward with fifteen other beds in. The following is a shortnotice of the case :-William W--, aged thirty-four, a labourer, living in

King’s-road, Fulham, one month before knocked the skinoiF the front of his left leg. It nearly healed; but threedays ago it began to get very painful, and rapidly increasedin size. On admission, there was a sloughy ulcer on thefront of the left leg the size’-of a penny; edges sharp andeverted. He was ordered twenty minims of tincture ofopium, fifteen. grains of chlorate of potash, and chinchonadraught, three times a day; with meat and porter. Theulceration did not spread after his admission. The sloughseparated, and the ulcer is now rapidly healing.

KING’S COLLEGE HOSPITAL.CEREBRAL HÆMORRHAGE IN A PATIENT TWELVE YEARS

OF AGE; HEMIPLEGIA; APHASIA; SUBSEQUENTMENINGITIS.

(Under the care of Dr. KELLY.)THE source of the hæmorrhage in the brain in the fol-

lowing case seems to have been due to previous plugging

of an artery by a detached vegetation in the left ventricleand it is the more likely as there was evidence of a similarplug in the kidney. The plug, having caused atrophicsoftening in the brain, some large vessel probably gave waythrough losing its support, and this took place on Aug. 1st,when the boy was suddenly seized with his illness. In threeor four days meningitis supervened in consequence of theeffused clot acting as a foreign body in the brain. Althoughthe patient’s heart was frequently listened to, no bruit couldbe heard. It was evident from the symptoms that thelesion involved the front part of the left hemisphere; butit was not until after death, that the nature of the diseasecould be clearly made out.H. C-, aged twelve, was admitted on Aug. 2nd. He

had always had good health, and had never suffered fromany previous illness. On July 24th he complained of painin the left side of his head, but had no convulsion; he ateand slept well. On Aug. 1st he partook very freely of goose-berries and currants, and in the night his mother wasalarmed by hearing him scream out. He was soon after-wards brought to the hospital in :’u state of complete insen-sibility. He was a strumous-looking lad, and his fingerswere much clubbed. He lay on his back, breathing in astertorous manner. His left eye was much suffused, andthe pupil larger than the right one; there was also a slightconvergent squint, but this he was said to have had for along time. There was no p,,trt,.Iysis either of the face or side,nor had he any fits, but occasionally moved his limbs in arestless manner. All over the chest were heard mucous1’a.les and sibilant sounds ; the heart’s action was quick andirregular, but no bruit could be heard. There was no riseof temperature, nor any taehe cerebrale. An aperient wasgiven him, and also an euema of castor oil. By this meansan immense quantity of undigested fruit was brought away.After this he seemed a little better, and was able to swallowa little milk.In a few days the temperature began to rise, and con-

tinued to do so during the whole of his illness; it rangedfrom 99° F. to 103° F., and at times the daily variations werevery great, varying from two to three degrees between themorning and evening observations.Aug. 5th.-I-Iis face was puTe, and the pupils nearly equal,

but they acted sluggishly to light. The lung sounds werenow quite normal, and he seemed to be rather more con-scious, and could take his food better. The pulse was irre-gular and rapid, and the heart’s impulse stronger thanusual. He was placed on milk and beef-tea diet. Therewere no convulsions nor twitchings of the extremities, nordid be vomit at all until towards the end of his illness.

10th. - He seemed mere sensible, and was able to take alittle rice p:u’clding. He knew when his meal-time came, butcould not ask for anything. He had at first passed hismotions unconsciously, hut now he bad control over hisrectam and bladder. It was now noticed that his face wasslightly paralysed on the right side, and also that the rightarm and leg were motionless ; this was more marked after-wards, but at no time was the facial palsy complete. Itwas difficult to make out whether sensation was impaired,as he was in such a stupid condition. It was observed alsothat he never used any other word than "water"; when-ever he wanted anything or recognised anybody, he alwayssaid °‘ Water." Not being able to write, it was impossibleto make cut how far his handwriting was altered.No marked change occurred until the end of the month,

when his temperature rose higher, and he was occasionallydelirious; his tongue, which before was moist, was nowbrown and dry, and his lips and teeth covered with sordes.He was never convulsed, but his left arm and leg wereoccasionally drawn up. The last day or two of his life, helay perfectly unconscious, in a state of low, muttering deli-rium. At no time was any bruit heard over the heart, butthe impulse was greater than usual.A post-mortem examination was made twelve hours after

death. The body was much emaciated, and of a sallow tint.On removing the skull the dura. mater was found normal;there was some soft recent lymph over the anterior part ofthe frontal lobes on either side of the falx cerebri ; a littlefluid was found at the 1-)ase; all over the base there wasrecent lymph gluing the parts together, and most abun-dant along the course of the nerves and large vessels; no

542

grey tubercle was met with in the fissure of Sylvius or else-where. The ventricles were much distended with fluid andtheir lining membrane thickened and softened; there wassome soft lymph over each choroid plexus. On the left side,in the middle lobe, was a clot of firm, coagulated blood aslarge as a plum, and nearly circular; internally it wasbounded by the optic thalamus, which was partly destroyedby the surrounding softening; externally it extended towithin half an inch of the circumferenee ; behind it reachedas far as the optic thalamus, and in front had partially de-stroyed the frontal convolution. But around the clot, forat least half an inch in every direction, the brain-tissue wasmuch softened. There was no atheroma nor plugging ofthe arteries, but they were difficult to dissect out because ofthe adhesions. No aneurism was seen, nor were the venoussinuses plugged. Both lungs were congested, and the rightbase was partly solid from pneumonia; it was red and gra-nular on section. Attached to the aortic and mitral valveswere large, recent vegetations; some also were attached tothe cords of the mitral valve, and had a loose, free extremity,from which a portion could be easily detached. There wereno clots in the heart, and no alteration in the lining mem-brane. In the left kidney was a puckered cicatrix ; in otherrespects the kidneys were healthy. All other organs in the

body were quite healthy.

Provincial Hospital Reports

HEREFORD GENERAL INFIRMARY.DISLOCATION OF THE RIGHT KNEE-JOINT; RUPTURE OF THE

POPLITEAL ARTERY; DRY GANGRENE; AMPUTATION;RECOVERY.

(Under the care of Mr. VEVERS.)G. D-, aged twenty, an agricultural labourer, in good

health, in ascending a ladder with a sack of corn, fell, dis-locating the head of the right tibia forwards. He is unableto describe the manner in which he alighted. He was ad-mitted on November 10th, 1869.On examination, the limb was found to be free from

ecchymosis. The lower end of the femur had been thrustinto the popliteal space, behind the head of the tibia,stretching, but not rupturing, the integuments, and pro-ducing marked deformity. The foot was swollen, painful,benumbed, and cool, and pulsation was not perceptible inthe posterior tibial artery. Reduction having been effectedby flexion and slight extension under chloroform, the limb,somewhat bent at the knee, and with the foot raised, wasplaced upon a double-inclined plane. Subsequently, dis-coloration of the foot, and later of the calf, took place,varying in hue from black to brick-red, and white; the ex-tremity became quite cold, and blebs appeared, accom-panied by gradually ascending insensibility of the leg.On the 19th of November a line of demarcation com-

menced a little below the knee. There was remarkablefreedom from constitutional disturbance throughout.November 20th. - Amputation was performed, under

chloroform, in the lower third of the thigh, by antero-pos-terior flaps; these were brought together with wire sutures,and covered with lint soaked in carbolised oil. The stumprapidly healed, having exhibited neither redness nor tume-faction. An inconsiderable amount of pus exuded, chieflyfrom the ligature tracks.January 2nd, 1869.-Discharged, quite well.Condition of the limb.-Although the popliteal artery was

found to have been ruptured opposite the flexion of theknee-joint, there was little extravasation of blood; bothends of the torn vessel were well contracted, and drawnwithin its cellular sheath. A considerable clot occupiedthe upper portion, extending as a white cylinder of smallsize about half an inch beyond the first collateral branch.The lower portion was well, but less securely, plugged. Atthe point where the venæ comites unite, and upwards asfar as their junction with the external saphena, the veinswere full of dark blood, nearly resembling treacle. In thissituation they presented a fusiform appearance ; and above,the popliteal vein was contracted. Below, they were simi-larly distended, and there were large patches of extrava-

sated blood on the muscular surfaces, and in the cellulartissue. The popliteal nerve was smaller, stained, and flat-tened out, as if from pressure, where it rested on theswollen vein; the fibrillæ were also separated from eachother. The external lateral ligament was completely, andthe internal partly, broken at the condyles ; and there wasa large rent in the ligamentum posticum of Winslow fullyexposing the back of the joint. The crucial ligaments weretorn through their centre, yet the articular surfaces of thefemur and tibia retained their proper relative position.

Medical Societies.

CLINICAL SOCIETY OF LONDON.FRIDAY, OCTOBER 8TH.

MR. PAGET, PRESIDENT, IN THE CHAIR.

PRESIDENT’S ADDRESS.

MB. PAGET urged the members of the Society, not onlyto be active in writing and debating, but to be in all theirwork in the Society strictly clinical. He said that he fearedthere existed, even among’ the members of the Society, toolittle faith in the power of clinical research,-too greatreadiness to doubt all results and all suggestions which arenot according to our beliefs in physiology or anatomicalpathology,-too great readiness to accept and act upon de-ductions from other sciences, though they are not approvedby clinical evidence. He vindicated the claim of clinicalscience to be considered, in the same degree as any otherscience, self-sufficient. Self-sufficient, indeed, no sciencecould be, all being bound together by common facts andmutual illustrations, and the same cardinal rules of study.But, in whatever degree self-sufficiency and self-reliancemight be allowed to any department of science, in consi-deration of the speciality of its subject-matter and of itsmethod of investigation, in that same degree might self-sufficiency be justly claimed for clinical science. It couldnot be objected that in claiming the rights of special clinicalstudy, too narrow a field of inquiry would be enclosed. Thefield would be found wide and large enough for every mem-ber of the Society to take a different subject or method ofinvestigation, and make of it the work of a life. The newnomenclature of diseases did not enumerate all the subjects;but, many as they were, each might advantageously bestudied in many different ways. Of the most promisingmethods were pointed out-the collection of cases undis-turbed by treatment; of rare cases; of large collections fordeductions from mere numbers of the simplest facts; of

groups of cases having one striking common character,such as the character of explosion of nerve-force, or thatof nerve-storms; of clinical coincidences, such as those ofdiseased renal capsules with coloration of the skin; andclinical sequences, like those of syphilis, in likeness towhich it appeared probable that others might have trainsof consequences extending over far longer periods of timethan they had yet been traced in. Referring to therapeu-tical inquiries, in which disappointment had been expressedthat the Clinical Society had achieved no great results, thenecessity was pointed out of discriminating between themanagement of a disease and the cure of it. No one talkedof curing pysemia or of managing ague. We manage pyæmia,helping the patient to live while, by natural processes, thedisease continues, and then subsides : we cure ague. In

respect of cures, there seemed too great a tendency to adoptthe popular belief that for every disease there must be aremedy; whereas, there is rather no reason to be givenfrom the nature of things why any disease should have aremedy; and in all biology there appears no more singularfact than the real cure of disease, after the manner of agueby chinchona, or syphilis by mercury and iodide of potassium.Such facts as these cannot but be rare, and very difficult ofdiscovery; but the search for them was one of those linesof inquiry in which the reward of success would bear ajust proportion to the toil for achieving it. If every memberof the Society, according to his power, or taste, or opportu-nities, would choose his own subject, and his own mode of