DEVON AND EXETER HOSPITAL.

1060

A Mirror HOSPITAL PRACTICE, OF

BRITISH AND FOREIGN. Nulla autem est alia pro certo noscendi via, nIsi quamplurimas et mor. borum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparare.-MORGAGNI De Sed. et Caus. Morb., lib. iv. Prooemium. -

UNIVERSITY COLLEGE HOSPITAL. DISLOCATION FORWARDS OF THE HEAD OF THE BADIUS REDUCTION SEVEN WEEKS AFTER THE ACCIDENT, RESULTING IN A FREELY MOVABLE JOINT.

;

any general swelling of the left elbow joint, but there was evident thickening round the head of the radius. The movements of the joint were exceedingly good; thus complete’ extension could be made, though over-extension was impos-. sible. Flexion was arrested when the forearm made an angle. of about 40° with the arm. Pronation and supination of the forearm were perfect. The distance from the acromial angleto the external humeral condyle was the same on the two. sides-viz , 84 is. The greatest length of the left ulna was 74 in., that of the rierht 7$in., and the greatest length of the left radius was 614 in. and that of the right 7 in. The patient was seen for the last time on July 17th ; he had been using his arm freely since June 26th ; there had been no, recurrence of the dislocation, and the conditions of the joint. were the same as on the previous date.

(Under the care of Mr. CHRISTOPHER HEATH.) DEVON AND EXETER HOSPITAL. WE give the notes of a case of displacement forward of the MIDDLE EAR DISEASE ; CEREBRAL ABSCESS ; OPERATION ; head of the radius, which was apparently overlooked for RECOVERY. seven weeks, partly to draw attention to this injury and the care of Mr. C. E. W. BELL.) (Under to show the that such a be reduced and dislocation may partly WE have published in the last two issues of THE LANCET" limb retain its proper position, though it has been displaced for some time. The following extract from Hamilton will examples of septic thrombosis of the lateral sinus in which We now bring forward theshow the difficulty of treating this dislocation : "Denuc6 life was saved by operation. of otitis media, also successaccount of another ’The reduction is more often complication says, frequently impossible; still, difficult to maintain.’ In proof of which he refers to fully treated, one which is not less formidable than that BaenDanzan and Robert. In the case of recent dislocation tioned, which requires equal skill for the diagnosis aad also’ related by Robert it was found impossible to maintain a for the treatment--viz., cerebral abscess. The history an this. reduction which he thought he had several times accom- case was of chronic purulent discharge from the cuddle eauplished, and he believed that the difficulty consisted in a (without mastoid suppuration), severe headache, C()}J.7’ll’lswf;! portion of the torn annular ligament having become entangled between the head of the radius and the condyle of attacks, double optic neuritis, and then the onset 01 unconthe humerus. Sir Astley Cooper was unable to accom- sciousness, with a slow pulse, but there is no history of vomitthe in two recent cases, and of the six ing, of rigors, or of any change in the temperature, whilst reduction plish cases which came under his immediate observation only two there appear to have been no external signs of the Iarg&a)8sss&< were even reduced. Malgaigne says that in a collection of situated in the temporo-sphenoidal lobe. Dr.K6rner-’b2&3ometwenty-five cases which he made the accident was unre- to the following, amongst other conclusions, from a ftt’& o:::f cognised or neglected in six, and ineffectual efforts at re- 100 cases of cerebral abscess. 1. Regarding diagnosis bs!!weem duction had been made in eleven, so that only eight of the abscess in the temporo- sphenoidal lobe orinthe cerebellum threes whole number were reduced. I have myself met with six points must be borne in mind : (a) cerebral abseesse are thre(t of these simple dislocations which were not reduced." times as frequent as cerebellar abscesses in children under 21 Three of these had not been recognised, one had been un- years old ; (b) the seat of the primary bone lesion ; (3) labyskillfully and unsuccessfully treated, one had become re- rinthine disease does not certainly indicate cerebellar abscess x; dislocated after reduction, and Hamilton was unable to (d) a painful area may be located by percussion. 2. Pain,. reduce the other himself on the seventh day. For the notes dizziness, and optic neuritis are uncertain signs. 3. Dis-of this case we are indebted to Mr. G. B. Mower White, turbances of speech occur in cerebral affections only, but are seldom met with on account of the preponderance of right-surgical registrar. The patient, a boy eight years of age, fell from a swing on sided abscesses. For the notes of this case we are indebtedt April 15th of this year, and attempted to save himself by to Mr. H. Andrew, house surgeon. A single woman aged twenty-one was admitted to hospitals extending his left upper limb. The left hand, which first met the ground, received the whole weight of the body, on July 12th of this year in a comatose condition ; the pupils. while at the same time the elbow-joint was extended. That were dilated (atropine had been used two days previously for this was so was learnt by the patient demonstrating the examination of the eyes) and equal, the breathing wasmanner in which he fell. Immediately after the accident stertorous, and the pulse was 56 and full. There was nc> there was inability to bend the elbow-joint, and a little later oedema of the scalp. When five years old she had scarlet. much swelling of the joint occurred. On May 26th-a period of fever, followed by a discharge from the left ear, but had otherwise always been strong, though somewhat neurotic.. seven weeks, all but one day, after the accident-tbe patient was brought to University College Hospital. There was During the last three months she had looked paler than. then a complete dislocation forwards of the head of the left usual and on June 22nd began to complain of pain over radius, with inability to flex the elbow. There was scarcely the left side of the face.-On the 27th the pain continued to any swelling of the tissues round the joint, and no be severe and she had a convulsive fit.-On July 3rd three, other injury (dislocation or fracture) could be detected. teeth were extracted, and for the next few days she felt. Under an anaesthetic (chloroform) Mr. Heath effected a better.-On the 6th she went out to see the procession. reduction of the dislocation by traction on the fore- in honour of the Royal Wedding, and was much worsearm with one hand and manipulation of the head of the in the evening and had several fits. - On the 7th the. radius into its proper position with the other. After reduc- pain in the head, especially in the back of it, was very tion the forearm was forcibly flexed to an acute angle with severe.-On the llth Mr. Roper, who had been attending for the arm and firmly bandaged across the front of the chest, the last few days and was treating the ear, made out slight, the tips of the fingers touching the right shoulder. The double optic neuritis.--On the 12th she complained of very limb remained in this position until June 2nd, when the great pain and about 11 A.M. became unconscious. Shebandages were removed ; the elbow-joint was extended two was admitted into the hospital for immediate operation. or three times, and the limb was again fixed to the trunk The head having previously been shaved and thoroughly with the forearm, now forming a right angle with the arm. cleansed, an incision was made on the left side one an
Fractures and Dislocations, p. 618.

1

Sajous, vol. ii., Annual of the Universal Medical Sciences, 1893.

1061 along the side of the needle and opened, when about two once, but after three or four days began to rise, reaching of thick, offensive-smelling pus escaped. A large 103° on Aug. 12th, when ten ounces were removed. From drainage-tube was inserted, and the superficial wound was this time the temperature gradually fell to normal, and has partly closed and dressed with sal-alembroth dressings.- continued so ever since ; and on Sept. 5th the patient was Up to the 16th the discharge had been slight, but on the discharged with the following result : the left chest was morning of that day there was a little more, with blood, and slightly flattened ; on inspiration it was sucked in over the the tube was shortened. She had spoken once since the region of the heart; the apex-beat was felt behind and to the operation, and had said "yes." The urine was drawn off left of the sternum ; the measurement of the left chest was regularly with a catheter. She had not been able to swallow 10 in. and that of the right 12 in. Percussion gave slight ood, so was fed by the rectum. Immediately after the opera- dulness from the third left rib in front ; the breath sounds tion the pulse rose to 88, at about which point it remained. were now quite audible, but diminished ; there was no pericardial rub. The right shoulder was raised, but this was due ’The temperature was normal. 18th.-The tube was again shortened. The discharge is to the persisting spinal curvature. Behind, both bases were less offensive. She takes milk well by the mouth and speaks resonant, and the breath-sounds were equally distinct on both sides. The child had gained in weight, expressed himself as when she is spoken to. 30th.-The tube was left out altogether and she is very feeling quite well, and had improved in appearance. CASE 2.-A girl aged fourteen was admitted on Aug. 6th much better, but is restless and has some loss of memory. Aug. 31st.-She was discharged ;the memory is still faulty, complaining of a cough for three weeks, of hurried breathing, and of pain in the left chest. She had never had any prebut in all other respects she is well. Oct. 2nd.-Up to this date she remains well, with a steady vious illness, but had lately been nursing and sleeping with a ounces

younger sister who had had inflammation of the lungs. The patient had been in bed herself for fourteen days previously to admission, and stated that she had spat up a great deal of blood and phlegm, and had had also considerBRIDGWATER INFIRMARY. able perspiration and great restlessness. On admission to the infirmary she was thin and very pale, with a hectic TWO CASES OF EMPYEMA TREATED BY REPEATED flush on each cheek. She seemed to be quite exhausted ; the ASPIRATION; RECOVERY. was very hurried and shallow. She had pain in the breathing (Under the care of Mr. R. HENRY F. ROUTH.) left side, frequent coughing, and expectoration of pus. The THE treatment of empyema by means of aspiration was temperature was 1024°, with a very small, rapid, and irresuccessfully carried out in the cases here recorded by Mr. gular pulse. The chest was seemingly well formed ; the left Routh. Both the patients were children, and in both aspira- chest was immovable, the lower intercostal spaces bulging. She had some herpes at the angle of the mouth. The alas nasi tion was performed several times. In the first case the chest were moving with respiration. Anorexia was present. The was tapped on five occasions, the first puncture being made heart’s apex-beat was felt to the right of the sternum in the for diagnostic purposes. Five days afterwards the side was fourth space. The pulse was 130. On percussing the left chest aspirated, aspiration repeated fifteen days after, thirty-three there was found to be absolute dulness from the second space, all round to the back, but not so well marked. days after that, and finally thirteen days later-the quantity extending The breath sounds were inaudible, except at the apex of the of pus removed varying on each occasion. In the second case, where the girl was older, aspiration was resorted to at once on left side. Vocal resonance was absent ; but at the angle of the scapula the breath sounds were just audible. admission, again a week later, then four days subsequently, and The patient’s condition being deemed very critical, she was repeated for the last time in three days. The cases remind was immediately aspirated in the sixth space in the axilus of a fact which is apt to be lost sight of in these days of line, and forty-five ounces of pus were removed. Great .aseptic incision and drainage, that aspiration is undoubtedly lary relief to all the symptoms was immediate. Although this .a curative method of treatment in children, but usually was only looked upon as a preliminary to excision requires to be repeated. If it is undertaken the patient aspiration should be carefully watched and the chest tapped at once if of a rib and drainage, the patient improved so markedly after ’re-accumulation of the fluid takes place. Again, it must not it that it was resolved to postpone the major operanormal and the be forgotten that this method is not a certain means of cure, tion. The temperature at once dropped to the ran up to On 14th pulse Aug. improved. temperature and should be given up when the tendency of the pus to and thirty-eight re-accumulate is very marked. It must also be recollected 100 ’4°; the patient was again aspirated that time is of great importance in the treatment of ounces of pus were removed. Again the temperature fell, and it remained down for four days. On the 18tb, as the line
’improvement in her memory.

hyper-resonant

apex. The breath sounds at the left apex were increased, being very feeble below that and inaudible behind. Pericardial friction was distinctly heard. The temperature was 100° F., and the pulse 105. A needle was put into the chest, and pus drawn from the front, but none from a puncture made behind.-On the 12th the temperature was 101°, and twelve ounces and a half of pus werp removed by aspiration. The temperature became normal next day and remained so for ten days, afterwards rising to 101 ’.-On the 27th eleven ounces of pus were removed. The temperature then became normal and remained so until -July 25th, when it began to rise, and on the 30th it reached 102 The patient’s chest was again aspirated, and fifteen sources of pus were drawn off. The temperature dropped at

BACTERIOLOGY

AT

KING’S COLLEGE.-The number

of students who attended the Bacteriological Department at King’s College during the session 1892-93 was 153, made up as follows : Post-graduate Lectures and Practical Course, 61; Laboratory Course, 19 ; Evening Lectures and Practical Course, 54 ; Course for Diploma of Public Health, 6 ; and 13 students who attended the Demonstrations for Students in For the session 1893-94 up to Oct. 19th Public Health. there were 17 entries for the Post-graduate Lectures and Practical Course, 6 for Laboratory Course, 31 for the Evening Lectures and Practical Course, and 1 for the Course for the Public Health Diploma : making a total of 55.