660

acid.-Evening : Pulse 76; temperature 98". Another whitepatch anterior to the other; tongue rather white; abdomendecidedly tender. No tenderness on pressing in lumbarregions ; passed about a pint of urine of a deep porter colour(brown with a greenish tinge) and smelling strongly of car-bolic acid.August 1st, morning : Her mother administered an enema

of soap-and-water almost without result.-Evening: Tonguevery white; another white patch on hard palate; fauces redand swollen ; less easy to swallow. Diet ordered to consistof milk and lime-water only. Patient slept well for fourhours last night; jerks a little at times; the abdomen ismore tender. There is considerable pain when pressed inlumbar region. A pint of urine has been passed, still darkand smelling of carbolic acid.-2nd, 9 A. M. : Dr. S anders con-sidered her worse.-1 P.M. : Skin cool; tongue whiter; faucesmore swollen ; abdomen and loins more tender; no urine passed.It being clear the last enema had quite failed, I administeredmore than three quarts of soap-and-water, which caused alittle vomiting (an ounce) and afterwards a copious clayeymotion.-3rd : No sleep last night from irritability of skin,which is now as red as a lobster; urine but little darkerthan natural ; whiteness of tongue and tenderness diminish-ing. Temperature 960. Hungry. - 4th, noon : Rednessgone; little tenderness; no urine; tongue white; cryingfor food. Allowed four ounces of bread cut into a sauce-panful of boiling milk, but it caused pain.-5th: Several pintsof healthy urine; no motion. To repeat the bread, also tohave cocoa, sago, and jelly.—6th : Tongue white, tendernessalmost gone. To have half an ounce of castor oil.-7th :Pain after oil, none since; to leave her bed. Has continuedwell up to the present date. I subsequently found thevomited matter exceeded two gallons.The above is the case referred to by Messrs. Calvert and

Co. It would lead me to consider that when the acid is incombination with tar oils absorption and assimilation takeplace, but may be retarded. A case reported in THELANCET of August 18th, 1883, bears out this view; alsothat in these and other cases of poisoning, where the anti-dote is so little objectionable, it is desirable by repeatedlydistending the stomach with it to endeavour to relieveit of all traces of offending matter.South Molton.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

PADDINGTON-GREEN CHILDREN’S HOSPITAL.TUBERCULAR MENINGITIS IN AN INFANT ; DEATH ;

NECROPSY; REMARKS.

(Under the care of Dr. Y. DAWSON.)

Nullaautem estalfa pro certo noscendivia, nisiquamplurimas et morbornmetdissectionum historias, tum aliorum tum proprias collectas habere, etinter se comparare.—MORGAGNI De Sed. et Caua. Morb., lib, iv. Proc8mium

FOR the following notes of this case we are indebted toDr. F. T. Hebb, house-surgeon.

J. G-, aged one year and three-quarters, was admittedon February 6th, 1884. He appeared half unconscious. Themother had died soon after the child was born. The father

says her death was caused by a " bleeding cancer and con-sumption." The child fell ill about four days before hebecame an in-patient; he refused his milk, he was sick onceor twice, and was once slightly convulsed. When admittedthe symptoms present were a pretty constant apasm of thecorrugator supercilii. He sometimes ground his teeth and wasapathetic, apparently regardless of surrounding objects ; abright light, however, seemed to cause distress. The pupilswere dilated and somewhat sluggish, the bowels were open,but the motions were offensive; he took milk fairly well.Temperature 97°. -Feb. 8th : The child has become morerestless, he moves his head from side to side; he often grindshis teeth; sometimes the hydrocephalic cry is heard; respi-ration is somewhat hurried, but the rhythm is regular; themucous membrane of the lips is dry and flabby; tongue ratherfurred; anterior fontanelle full. A slight dry cough recurspretty often, but the lungs are clear. He remains for the

most part in a sort of stupor; takes his milk well. Tem-perature 98°.—9th : The pulse has now become peculiar incharacter; for several beats it is full and fairly slow, andthen follow several hurried pulsations, somewhat irregularand feeble. Respirations are regular in rhythm, but thedepth of inspiration varies; several successive inspirationsare deep, then follow several much more shallow. Hesquints occasionally, but there is no inequality of the pupils.The upper eyelids are periodically raised, and after ashort interval slowly lowered. The abdomen is somewhatretracted, and the taches cérébrales are very apparent,; thehands are often raised to the head. Temperature 100’2°;bowels confined.—12th : The pupils rhythmically dilate andcontract; the abdomen is much more retracted; the childis more apathetic ; he refuses his milk; the other symptomsremain as before.—13th : He is slightly convulsed, especiallyon the right side; superficial veins of head much distended.Temperature 96’8°; child somewhat comatose; conjunctivainjected ; abdomen excessively retracted. Later on in theday the convulsions became pretty frequent, and assumed amore general character, but still they were more marked onthe right side; he lies with his eyes half closed, nearlyunconscious; it requires a fairly strong stimulus to awakensensibility ; the corrugator and occipito-frontalis have ceasedto contract.-14th: Convulsions have ceased; symptoms ofhypostatic congestion of the lungs ; respiration very quick.Temperature 100’4°; he refuses his milk ; the other sym.ptoms remain as before.—18th: The child died to-day veryquietly. Two days ago the convulsions began again, butthey soon ceased; there was inequality of the pupils. Theother symptoms remained more or less unchanged.

Necropsy, twenty hours after death.-Only the brain wasexamined. There was a large amount of cerebro-spinalfluid at the base of the brain. The small arteries at thebase appeared somewhat more congested than usual, butno tubercles could be seen with the naked eye.

, Remarks by Dr. DAWSON.-The microscopic preparationsof the pia mater made by Dr. R. Grainger Hebb, thepathologist to Westminster Hospital, showed the tuberclein the early stage before caseation had taken place, andexhibited the bacillus tuberculosus in considerable numberson a patch of pia mater adherent to an arteriole at the base ofthe brain. The bacilli were very well seen, and their appear-ance was further corroborated by my colleague, Dr. LeslieOgilvie. The interest in this case lies in the discoveryof the bacillus tuberculosus in the membranes of the brainin a case of tubercular meningitis at so early a stage; foralthough their existence in the meninges in general tuber-culosus was demonstrated by Cornil lately in Paris, theirpresence in the brain prior to caseous degeneration has not,so far as I am aware, been hitherto noticed in this country.

NEWCASTLE-ON-TYNE INFIRMARY.UNUNITED FRACTURES OF BOTH PATELLÆ ; FRAGMENTS

OF LEFT PATELLA WIRED ; RECOVERY.

(Under the care of Mr. PAGE. )R. H-, aged fifty-four, a stableman, was admitted on

November 4th, 1883, suffering from ununited fracture of bothpatellæ. The right patella was broken fifteen years ago byfalling upon his knee, since when his knee-cap has rested(about two and a half inches above the condyles) on theanterior surface of the femur, where it is quite fixed.Neither the ligamentum patellae nor any portion of thepatella can be felt below the knee-joint. The patient canboth flex and extend his knee, the latter movement beingevidently produced by the expansion of the lateral por-tion of the quadriceps extensor tendon. Seventeen weeksbefore his admission the patient was kicked by a ponyon both knees, when he sustained a fracture of the leftpatella and a fracture of the right tibia immediately belowthe knee-joint. On his admission into hospital there wasno union of the left patella; both fragments were wideapart. The patient was quite unable to stand ; when-ever he attempted to do so his knees bent under him.It may be stated that before the second accident the patientwas able to follow his occupation as a stableman.-17th : Mr. Page made a longitudinal incision over the frontof the knee-joint, so as to expose the patella. The lowerfragment was also fractured longitudinally. The fracturedsurfaces were freshened and drawn together with strongsilver wire. The wire was hammered down on the face of the

661

patella. The wound was closed with catgut sutures. Threedrainage-tubes were inserted, one on either side and onebetween the patella and skin. Lister’s dressings were used.-18th : The patient has had a good night, with the exceptionof some pain, which was relieved by a quarter of a grain ofmorphia. The wound was dressed under the spray, a con-siderable quantity of blood-stained synovia having escaped.Temperature 98’6°.-20th : Temperature 99-8°. The woundwas dressed. The drainage-tubes were removed, and werefound filled with blood-clot ; having been shortened, thetubes were reintroduced. The dressings were very littlestained.—25th: There was very little discharge of synovia ;no pus. Temperature 99’4°. -27th : The drainage-tubeswere removed, and the antiseptic dressings discontinued, apad of absorbent cotton-wool being put round the joint.Dec. 4th.-The wound was closed.Jan. 3rd, 1884.-A plaster-of-Paris splint was applied, and

the patient moved about with the aid of crutches.-25th: Thesplint was removed.Feb. 2nd.—Passive movementused.—11th: The patient can

now bend his knee to an angle of 40° and straighten it again.

STRATFORD-ON-AVON INFIRMARY.SURGICAL CASES.

CASE 1. Ruptured Perineum. (Under the care of Mr.Mason).-Jane R-, aged thirty-one, was delivered of herfirst child in October last, sustaining a rupture of the peri-neum from the fourchette back into, but not through, thesubstance of the sphincter muscle. On Feb. 4th, the patientbeing under the influence of chloroform and in lithotomyposition, Mr. Mason pared the edges of the rent, bringingthe parts together with six sutures, three deep and threesuperficial. Satisfactory union has taken place.CASE 2. Submaxillary Adenomct. (Under the care of

Mr. Lupton.)-Mary H-, aged fifteen, was admitted onJan. 18th with a large tumour extending from near thesymphysis almost to the angle of the jaw on the right side.She stated that it had prevented her getting a place, and wasanxious for its removal. On Jan. 21st, the patient beingunder chloroform, Mr. Lupton removed the tumour. The

posterior attachments were deep, and the facial artery wasdivided in dissecting them out. The wound has healedkindly throughout, but the ligature on the facial has notyet (30th day) come away. The tumour was a simpleglandular tumour.CASE 3. Lithotomy. (Under the care of Mr. Lupton.)-

Joseph B-, aged eighteen, was sent into the infirmary onJan. 30th, 1884, by Mr. Laughton, surgeon, suffering fromcdsulus. He states that he had no symptoms till themiddle of December, 1883, when he was troubled by astoppage of his water. After this he had pain and troubleconstantly till December 22nd, when he again had stoppage,but passed water naturally on the 23rd. About a fortnightlater he again had stoppage, relieved by Mr. Laughton,who, on passing a catheter, felt a stone. Since then he hashad constant dribbling of urine. On admission, the presence ofa calculus was detected by a sound. Urine alkaline, con-tained much viscid, ropy mucus, and a few crystals of triple phos-phates.—Jan. 31st: Bowels relieved freely by enema. Orderedfive grains of compound soap pill at bedtime, being in muchpain.-Feb. 1st: Urine alkaline, sp. gr. 1015; much mucus ;no albumen. Pulse 86 ; temperature 98 2°. Appetite fair ;tongue clean. - Feb. 6th : Urine alkaline, sp. gr. 1016 ;much mucus. Patient’s general condition much improved.On the 8th a rise of temperature, difficult to account for,commenced. On the evening of the 9th it stood at 102°, andby noon on the 10th at 103°; by the evening of the 10th ithad fallen to 100°, and on the llth fell again to normal. Onthe 13th lithotomy was performed by Mr. Lupton at noon.A calculus weighing 62 grains, and measuring 2 1/16 in. longby 1 5/16 in. broad, was extracted. A momentary delay wasoccasioned by the stone being seized across its long axis,which was speedily set right by a finger in the rectum. ABuckston Browne’s lithotomy tube with tampon was securedin the bladder and the patient put to bed. A morphiasuppository was given at 5 p, M. At 9 P. M. he was sleepingsoundly; there was no haemorrhage, and a free secretion ofurine passed through the tube. Pulse 70; temperature 100°. ]On the following day (14th) the temperature fell to 93°, and ]on the 15th regained the normal.—15th, noun : Tube re-

moved. Patient doing well. - 19th : Firat urine from t

urethram. The patient has since done uninterruptedlywell.CASE 4. Incarcerated Hernia (Seven Days) Herni-

otomy. (Under the care of Mr. Lupton.)-Jas. A-,aged fifty-nine, shoemaker, was sent in on February13th by Mr. Latimer Greene. He had an old congenitalhernia, which he had always been able to reduce until aweek previously, and for which he had always worn a truss.The hernia was not tense, and though not reducible, theordinary signs of strangulation were absent. A fair trial oftaxis was made under chloroform ; but that failing ice wasapplied for twelve hours, and the taxis again unsuccess-fully resorted to. The patient was kept on low diet, whichhe failed to appreciate, and ice kept constantly applied tothe tumour. A free action of the bowels followed theadministration of an enema on the 13th, but the hernia wasstill irreducible. On the evening of the 16th, the herniabecoming more painful, and nausea setting in, Mr. Lupton,after consulting with his colleagues, decided to operate.Chloroform was administered by Mr. Norbury, and theoperation performed in the usual manner, after a finalattempt to reduce by taxis had failed. The hernia wasfound to contain cæcum and colon, and, even after the neckof the sac had been twice freely incised, was only returnedwith much difficulty. The operation was prolonged, and thebowel exposed to much more handling than was desirable.The temperature rose to only 99° after the operation. Thebowels acted naturally on the second day ; and, in, fact, itmay be said that the patient has recovered, so far, withoutany bad symptom. The wound has been only twice dressed,under antiseptic precautionq, and is healthy.

AYR COUNTY HOSPITAL.LEFT ARM TORN OFF WITH COMPOUND FRACTURE OF

RIGHT LEG; RECOVERY; REMARKS.

(Under the care of Dr. W. J. NAISMITH.)FOR the notes of the following case we are indebted to

Mr. W. A. Malcolm, M.B., C.M.Edin., house surgeon.A. G-, a well-grown boy of fourteen years, was

admitted to " Oswald ward of the Ayr County Hospital onNovember 28th, 1883, with the left arm torn away, and withfracture of both bones of the right leg immediately abovethe ankle, that of the fibula being compound, with, however,a very small wound. When brought in he was only halfconscious, pale, and almost pulseless, the usual signs ofgrave systemic shock. It was noticed that his left pupil waswidely dilated, the right being normal. The boy hadwandered into a timber yard, and, at the suggestion of acomrade, placed his left arm round the shaft of a steam sawwhich was revolving at full speed, three feet from the ground,"just to see how it would feel." The trunk was engaged ina moment, whirled round with frightful velocity and dashedto the ground, the arm being completely torn away. Noinformation could be obtained as to the number of revolu-tions before disengagement. As might have been expected,there was little or no haemorrhage. The patient beingrevived by stimulants and anæsthetised, the removal ofthe temporary bandages revealed an ugly wound, fromthe centre of which protruded about an inch and a

half of the spiculated upper fragment of the humerus, brokenoff close to the glenoid articulation, which was intact.The bruised and cord-like brachial artery, with the medianand musculo-spiral nerves, hung out independently from thewound for some four or five inches, and to the same extentlay some of the exposed and ruptured muscles connectingthe limb with the trunk. The fleshy masses of the deltoid,great pectoral, latissimus dor6i, and teres major wereexposed with the nicety of a dissection, and the skin andsubjacent cellular tissue had been cleanly removed from theentire region of the shoulder-that is to say, from the partwhich would be included by a line proceeding from theaxilla apex forward, with a curve across the great pectoral,upwards through the centre of the clavicle, downwards towithin an inch and a half of the dorsal spines, curving out-wards again to join the axilla. An extensive surface wasthus denuded, and skin flaps were therefore impossible.

Treatment.—The joint was not disarticulated, but theprotruding portion of the humerus was removed with bonepliers close to it. The brachial artery was tied as high upis possible and cut short, a couple of deltoideal brancnes ofhe posterior circumflex also required ligaturing. The