873

From March 24th the patient progressed favourably ; thefever rapidly abated, and the abdominal tenderness anddistension gradually ceased. On April 2nd the ligature wasfound to be quite loose, and was then withdrawn; the woundat this time closing rapidly by granulation. On the 6th,however, there was observed to be a tendency to sloughingalong the margins of the incision, and the surface of thewidely-gaping wound presented the appearance of an ulcerresulting from an ill-conditioned venereal bubo. On April9th the limb was kept flexed at the hip, black-wash appliedto the raw surface, and iodide of potash in 8-grain doseswith tartrate of iron in ten-grain doses ordered every fourhours. The ulcer then speedily closed by healthy granula-tion, a tendency to burrowing of pus towards the right flankbeing opposed by firm pressure with a pad and abdominalbandage. On May 10th the patient was allowed to get up,the wound being quite closed. On June lst he was reportedas cured. The aneurismal tumour, which had never pulsatedsince the application of the ligature, was then reduced to asmall hard swelling, the margins of which could not be dis-tinctly defined. Patient complained of slight stiffness inthe right hip, and of occasional numbness in the great toe.He was able to walk about without difficulty, and to dowork.

ST. GILES’S INFIRMARY, CAMBERWELL.CASE OF GRANULAR DISEASE OF THE KIDNEYS, WITH

HÆMORRHAGE FROM THE MUCOUS MEMBRANES.

(Under the care of Mr. THORBURN PATERSON.)IN the following case there was, with granular disease of

the kidneys, copious and numerous hsemorrhages from themucous membranes. In this instance, however, there wasno evidence to show that the patient had been exposed tothe poisonous action of copper, as in the case recentlyunder the care of Dr. Henry Thompson, and reported atp.798.

A. P--, aged fifty-seven, a cooper, was admitted intohospital on June 2nd, 1874. He had been ailing for sometime, and said he had been under treatment for ’° bilious-ness." His appetite for a long time had been very bad,and he had often vomited his food. During four weeksprevious to his admission he had been unable to work. Hesaid he was not intemperate, although he occasionally had"a glass or two." He had observed blood in his stools forabout a fortnight before he came into hospital. He hadnever had piles.His condition on June 3rd was as follows :-Face puffy

and of sallow complexion; conjunctiv2e of a yellowishtinge ; mucous membrane of lips and gums pale ; pulsestrong and full. There were slight involuntary twitchingsof the arms and fingers, like those of chorea. No anasarcaor other kind of dropsy beyond the puffiness of the face.The heart’s action was very powerful, and on auscultationa diastolic murmur was heard at the base. Faint mucousrales over upper lobes of lungs. The urine, six hours afterbeing voided, was pale, slightly alkaline, of sp. gr. 1011,and contained a large quantity of albumen. Under themicroscope, a large quantity of crystals of triple phosphate,with fragments of tube-casts and debris, were seen. Therewas considerable hæmorrhage from the bowels. The patientcould retain nothing on his stomach but a little brandy andiced water.June 4th.-Under treatment the bleeding from the

bowels ceased, but haemorrhage from the nose commenceda few hours afterwards. This epistaxis also subsided undertreatment, but broke out again and again repeatedly untilthe patient died.

5th. - Bowels constipated ; tympanites. An enema

brought away scybalous matter.6th.-Heart’s action irregular. The twitchings of the

hands and arms more severe and greatly distressing thepatient. The gums were not spongy, and had no blue orgreen line. The patient’s wife stated that he had only puton a few copper hoops in his lifetime, and had never workedamong lead.

7th.-Hæmorrhage from the bowels recurred. Patientcomplained of difficulty of breathing; his other symptomswere aggravated. He died early on the following morning.Autopsy.-The heart, after being freed from clots, weighed

twenty-one ounces; the right auricle contained a largefibrinous clot lying in the midst of dark blood, which waspartially coagulated; the wall of the right ventricle wasabout half an inch thick, and its cavity contained a littledark blood; the tricuspid valve admitted four fingers; thewall of the left ventricle averaged about 1 1/8 in. in thickness;its cavity was contracted and empty; the mitral valve ad-mitted the index and middle fingers together, and was strongand thickened, and the papillary muscles were firm and muchhypertrophied; the aortic valves were almost obliterated;the left auricle was empty. The lungs were spongy andosdematous, and only slightly collapsed when the chest wasopened; the bronchi, down to those which could admit aquill, were filled with white frothy mucus; the mucousmembrane of the bronchi was much congested, having aspeckled brown or purplish-brown colour, mingled in thelarger bronchi with florid streaks. The pleurae and peri-cardium were healthy, and contained a normal quantity of £fluid. The liver weighed 3 lb. 11 oz., and in structure washealthy. The gall-bladder contained fully 1 oz. of darkbile. The spleen weighed 5 oz., and was very friable. Themucous membrane of the stomach was greatly congestedthroughout, being of a dark livid colour,.marked here andthere with streaks of red; it was covered with glairy mucusand a small quantity of stercoraceous matter. The mucousmembranes of the intestines were also congested throughouttheir entire extent; there was no ulceration anywhere, butin the lower portion of the ileum, the descending colon, andthe rectum, there were streaks of blood; there were no suchstreaks in the upper portion of the intestine. The left kidneyweighed 3 oz., the right 2! oz.; the surface of each waspapulose, and the capsule almost entirely adherent; thecortical portion was almost gone, a part of it being apparentonly towards either extremity of the organ; the pyramidalportion was only partially distinct at the parts correspondingwith the portions of cortex which remained; the rest of thekidney consisted of yellow fatty strise mixed with blood-vessels and pieces of stroma. The mucous membrane of thebladder was remarkably pale, but was healthy in structure.The brain and spinal cord were not examined, owing to thewish of the patient’s relatives.

WEST BROMWICH HOSPITAL.GUNSHOT WOUND OF THE FACE; ERYSIPELAS;

RECOVERY.

(Under the care of Mr. SANSOME.)FoR the notes of the following case, and for the remarks

appended thereto, we are indebted to Mr. Richard Johnston,resident surgeon.Richard S-, aged twenty-one, collier, was admitted on

April lst at 3.30 P.M., suffering from the above injury.Whilst in the act of stooping to reach a fowling-piece,which was in the lower part of a dresser, he states thathe heard a click, and felt something strike him in the face.On hearing the report some neighbours came into the house,and found him lying on his back, about a yard from thegun, in a pool of blood. They sent for a surgeon, who,upon examining him, advised his immediate removal tohospital. From the patient’s account, at the time of theexplosion the muzzle of the gun was not more than a footfrom his face, pointing upwards and to the left.On admission the countenance was blanched, the ex-

tremities cold, pulse small, weak, irregular, and fluttering.On removing some rags, a wound was discovered, extendingfrom the angle of the mouth to the ear on the left side,with everted edges, and greatly charred ; the malar processof the superior maxilla, together with the lower portion ofthe malar bone, were lying loosely in it ; the trifacial nervewas much injured, and the superficial portion of the parotidgland was blown away. The duct of the parotid gland wasexposed, but escaped injury; the submaxillary gland wasalso partially exposed. The loose fragments of bone, someshot (about No. 8 in size), and unexploded grains of powder,having been removed, the wound was filled with sponges, asthere was considerable haemorrhage (oozing). In abouttwenty minutes, all bleeding having ceased, the edges weredrawn together with silver wire, and water-dressing applied.Upon examining the eve on the same side, the conjunctivawas found thickly studded with powder. At 8 P.M. he com-

plained of great pain, and was unable to pass his urine.

874

Ordered at once thirty drops of the sedative solution ofopium with fifteen drops of the spirit of chloroform. Tem-

perature 96 2° F.April 2nd.-Has had about three hours’ sleep. During the

night he passed urine. Morning temperature 100°; eveningtemperature 1013°. Repeat draught.3rd.-The bowels not having acted since admission, an

enema was ordered. Evening temperature 102°. Repeatdraught.4th.-The bowels have acted well. Morning tempera-

ture 101’2°.-8 P.M.: Has had rigors during the day ; tempe-rature 105°; remove water-dressing ; apply linseed-mealpoultices, to be changed every third hour. As the patientwas suffering from some gastric irritation, the hypodermicinjection of morphia was ordered.5th.-This morning there is a well-marked erysipelatous

blush around the wound. The patient is unable to openthe eye on the opposite side. The scalp to be shaved ; paintface and scalp with solution of perchloride of iron; to con-tinue poultices. Morning temperature 1023°; evening,103.1°.6th.-Morning temperature 100.2°. About 2.30 P.M. the

nurse reported that the patient had great difficulty ofbreathing, and complained of pain along the cervical anddorsal regions; his head drawn backwards; the recti mus-cles tense. Hypodermic injection of morphia was adminis-tered.-8.30 P.M.: Patient much easier; temperature 102°.7th.-The patient has passed a good night; does not

complain of so much pain along the spine. Morningtemperature 992°; evening, 100°.8th.-Spinal tenderness has completely subsided. Morn-

ing temperature, 982°; evening, 985°.9th.-Temperature, morning, 98°; evening, 983°.10th.-Swelling in the face has entirely disappeared.

Wound suppurating freely; dress with elemi ointment.Morning temperature, 981’; evening, 985°. From this idate the temperature fell to its normal standard. 16th.-The patient is progressing favourably. Omit

poultices ; parts to be drawn together; soap plaster.28th.-The wound is almost healed; the patient is unable

to open his jaw more than a quarter of an inch.May 1st.-Wound completely healed, but he has not

gained further power of separating the teeth.5th.-Discharged. ’

Remarks.-This case presents the following points of in-terest :-1. The great amount of injury which the structuresof the face are able to sustain without being fatal, and theextreme rapidity with which repair takes place, bearing outthe remarks of Mr. C. Heath. 2. The results attending theexternal application of iron in erysipelas. Out of six caseswhich have come under observation in this hospital, in threethe external application of iron alone was adhered to, andfollowed by most marked results. It may therefore be fairlyclaimed for this remedy, that it possesses a power far superiorto nitrate of silver in limiting the spread of erysipelatousinflammation. These facts lead us to endorse the statementof M. Velpeau, in his 11 Lecons Orales," who, speaking ofthe failure of other remedies, states, 11 I do not say it ex-tinguishes it as soon as it is in contact with it, but it iscertain that it sensibly shortens its duration, and an ery-sipelatous patch does not resist its application for morethan two or three days;" though some eminent surgicalauthorities would lead us to believe that it has little actionother than soon moulding the linen.

THE NERVES OF THE CAPSULE OF THE KNEE-JOINT OF THE RABBIT.-Dr. Carl Nicaladoni gives the

following as the conclusions at which he has arrivedfrom a long series of microscopical researches upon thenerves distributed to the knee-joint of the rabbit. Inthe first place, there are certain parts of the joint whichreceive an unusual supply of nerves. The medullated nerve-fibres composing one of the smaller trunks subdivide, withretention of their sheaths, in various modes, the ultimatebranches terminating in plexiform expansions of the axiscylinders, which are partly applied to the closely-arrangedcells of the endothelium of the tunica enterica of the joint,and are partly embedded in accumulations of the cellularstructures of the adventitia. A small part of the nervesare in very intimate relation with the vessels; the remainderform Pacinian corpuscles.-Med. Jahrb., Heft. 4, 1873. :

Reviews and Notices of Books.. The French Revolution and First Empire: an IlistoricaZ

Sketch. By W. O’CONNOR MORRIS, sometime Scholar ofOriel College, Oxford. London: Longmans and Co. 1874.-

’ The study of the stupendous events comprised in the periodembraced by the title of this book will never lose its at-traction. Victory has since shifted, and shifted with a ven-geance, from the standards of one race to those of another.

, France seems destined to be the great stage whereon poli-tical theories of various kinds, which in other countriesexist but in idea, are to be reduced to practice. As scenesucceeds scene in the eventful drama, who can tell what isto come, or who the principal actor is to be ? The

Napoleonic name has not yet lost its influence. Submergedbeneath the waters of national affiction, it seemed but

yesterday to have gone down never to rise again to an his-torical future. He would be a bold prophet, however, whowould declare to-day that the name of Napoleon had nofuture-that what was written concerning it was written inthe past pages of history. Time turns over many leaves,and who is to play the prominent part in the next chapter ?The whispered suspicion of to-day may to-morrow possiblybe proclaimed from the house top; and if there is to be afourth Napoleon, of what spirit will his rule be ? Thecharacter is now being moulded while it is still impression-able. Will its training in this country, and the memory ofthe past and its experiences, leave indelible marks ? and isthe French Empire of the future, if it ever comes, to be arepetition of its predecessors or the harbinger of happiertimes for France and Europe ? The events depicted in thisvolume, be they told ever so tamely, cannot fail to stir theblood, and, if they do not possess the power and brilliant.colouring of Carlyle’s narrative, they are nevertheless clearlydepicted, and Mr. Morris has set forth philosophically andably the causes as well as the consequences of the revolu-tion.

Observations on the Pathology and Treatment of Cholera.By Joarr MuRRAY, M.D., Inspector-General of Hospitals,late Bengal Medical Service. -Anticipating the invasionof England by cholera, and feeling that the "knowledgeof a rational system of treatment is much required,"Dr. Murray submita "the result of forty years’ experienceduring the lull that precedes the storm." The theory ofelimination of the poison he regards as sound, when re-stricted to excretion by the liver, kidneys, and lungs, andfreed from the risk of increased action of the bowels. This

leads to the use of calomel, or calomel and opium, under allcircumstances, and Dr. Murray says 11 in the hands of aphysician this is a powerful antidote." To aid the calomelin the early stages is administered one of Dr. Murray’sanodyne carminative pills, composed of one part of opium,two parts of black pepper, and three parts of assafoetida,and given in five-grain doses after every second stool. "InIndia these pills are kept in bottles at all hospitals and dis-pensaries, distributed in all barracks, in all police stations,and in the towns." An experience of some years in Indialeads us to conclude that this must refer to native hospitals,barracks, &c., and that, even there, the universal presenceof these pills must be due to Dr. Murray’s position as in-spector-general of hospitals, rather than to any extra-

ordinary virtue they possess. While we think that the

perusal of these 11 observations " might be advantageous toyoung medical officers, we are bound to confess that we failto find in the suggested remedy, or the succeeding sug-gestions, anything but what we have read over and overagain in other forms, and the results of which have beenfar from reassuring.