- Email: [email protected]
JERVIS-STREET HOSPITAL, DUBLIN.
741 for it. I shall then speak of the treatment. You have seen- many cases here, but- many JERVIS-STREET more- cases are met with in private practice which are not admissible into hospitals, the
HOSPITAL, DUBLIN.
CLINICAL REMARKS so very slight. Only the worst of stricture are admitted here. It BY is right that you should understand this, and you should be prepared to treat them DR. WALLACE. But there are a great many very difficult cases, for, indeed, many patients labouring under this disease have FRACTURES OF THE JA W. been bungled out of their lives " through JANUARY 19, 1836.-Ward No. 4.-Here, ignorance and inattention. This drawing represents mortification of the scrotum gentlemen, is a case of fractured jaw in a wofrom extravasation of urine. Patients do man ; let us compare it with the one in the not often survive under such mischief, or man in the ward No. 2 : the comparison will until the parts become thus disorganized; be useful. What are the relative situations of You saw some struggle through wonderfully, and ifthe fractures in these two cases ? incisions be not made, as they onght to be, that the man’s fracture was situated just at very early and very freely, the scrotum or the right side of the symphysis, that it passthe penis is often left uncovered and unpro- ed between the first and second incisors. And here let me remark, that fractures of tected. mention that occasionally the the jaw, although they are said to occur at passage ulcerates towards the corpus spon- the symphysis, never do take place in that giosum, and the urine is admitted into the situation, not really in it. This is what you vascular network, the penis becoming black might expect, when you reflect that the in consequence. It is not into the body of symphysis is much stronger than the part of the penis, but into the corpus spongiosum, the bone just connected with it, or at the that the infiltration occurs. The outer sur- side of it. You remark, that this woman has face of the glans, as you are aware, com- a fracture on the right side in precisely the municates freely with the spongy body, is, same situation as that of the man, but you in fact, a prolongation of that tissue. When see she has got a second fracture; the bone the glans becomes black, and sloughs, it is is broken on the left side also, immediately about one of the most alarming and fatal in front of its angle. This renders her case signs which we meet with, and many are fay more serious than that of the man. Obalarming enough in the disease. This is not serve what a difference there is between You saw that the man appeared to a very common occurrence, but Sir BEN- them. JAMIN BRODIE mentions, I think, two or suffer very little, and there was scarcely any three cases in which he noticed it, and in deformity. See how much the fragments all, the patients, I believe, perished. I have are here dispiaced; remark how this woseen the appearance also more than once, man appears to suffer, what agonizing pain but in one of the instances a fatal termina- she seems to experience about the fractured tion did not happen. The urine may in this angle, how the least motion of the head way be admitted at once into the blood, annoys her, and how she grasps her occiput and be returned by the veins into the with her hand to keep her head steady. mass of circulating fluid, and thus you can She discharges abundantly saliva from the account for the bad consequences which al- mouth, and is almost quite unable to artimost invariably follow, but still a fatal re- culate, whereas the man could speak very sult does not uniformly take place. distinctly. What is the cause of this great difference in these two cases ? I have often many of the distressing symptoms which you see in this woman, to arise when CURE OF ULCERS.—Dr. Cramer recom- the jaw was fractured far back; and I have mends for the treatment of ulcers, that a always supposed them to be owing to the piece of lint, imbued with the discharge, injury of the trunk of the sub-maxillary should be dipped in an impalpable powder of nerve, which you know enters the bone the nitrate of silver, and then reapplied to near its angle, and is, therefore, much exthe sore. This he repeats every day, or posed to injury in such cases as the present, every other day, and by his enforcing a quiet that is, when a fracture exists near the state of the member, he mentions his having angle. There is also another reason why succeeded in healing the most obstinate the double fracture in this woman should ulcers in a period of six or eight weeks. He produce much more serious consequences has likewise employed the same powder with than the single fracture in the man. The advantage to the granular conjunctiva.- depressors of the jaw are almost all attached to the middle fragment, while the elevaHeidelberg. Klinische Annal. tors are connected with the two posterior
danger is
cases
scientifically.
I should
observed
portions of the jaw; hence great displace..
742 ment must arise
the different parts of the jaw. You also remark what pain is given, their muscles in differ- whenever I attempt to raise this depressed ent directions. The middle portion is de- portion into contact with the upper jaw, or pressed, and the posterior portions are to a level with the other portion. You see raised, and this displacement is greatly faci- she will not allow this to be done; you can. litated by the direction of the fractures, not, in fact, by acting in this manner, either which is parallel to the line of direction in bring or retain the bones in their proper which the depressing muscles act, that is, situation, and even if no pain were produced, from above downwards, and from before the mechanism of the parts, and the direcbackwards. But in the man’s case, the tion in which the displacing muscles act, elevating muscles being connected with both would soon render your endeavonrs unavailfractured portions, the action of the de- ing. Well’ what should be done ? You pressors, which are connected with the large must, as I have said, depress the raised part, fragment, are greatly moderated, and hence you must bring it down to a level with the there is little displacement. broken fragment; and you do this by inter. Now how have these fractures been pro- posing a cork between the upper jaw and duced ? How has the fracture in the man the raised side, proportioning its thickness been produced? By a fall from a ladder on to the degree of displacement. You thus the chin. How has it been produced in the depress the raised side, and make it meet woman’s case ? By a blow on the left side of the depressed side. I shall now put in this the jaw. You can easily conceive, that the cork at the raised side. See what relief it mechanism of the forces which caused the affords ; I shall next pass this in at the other fractures in these two cases near the sym phy- side. You remark she cannot bear it; I sis was different, that is, the force did not must remove it. Now I shall apply a band. act in the one case, as it did in the other. age, as we did in the man’s case. This, In the man’s case, the tendency of the force then, is the mode of treating these fractures. was to straighten the jaw by pressing the In the one case, you apply a cork at both convexity of the chin inwards and back- sides; in the other, you apply it at one side wards, and the solution of continuity close only, and you see how admirably the differto the symphvsis commenced in the inside ence of treatment is suited to the two cases. of the jaw, and extended outwards. In I should mention to you, that it will some. this woman’s case, the force being applied times happen, that it will be useful in cases to the side of the jaw, the tendency of itsof double fracture to apply a second cork; action was to increase the natural curve of for example, in the present instance we the jaw, and the fracture near the symphysis might apply a cork between the posterior must have commenced externally, and passed teeth at the left side, not as it was applied inwards, and most probably the second between the upper jaw and the depressed fracture occurred subsequently to the first, fragment, but between the upper jaw and but by a continuance of the same force. the posterior and left fragment of the lower, What difference of treatment must be which is, as well as the right side of the jaw, adopted in these two cases ? You have ob- kept raised by the elevator muscles. This served that the man seems to be very com- would keep this portion of the jaw down to fortable under his injury; and all that has a level with the posterior end of the debeen done has been to retain, by a bandage pressed middle fragment. I generally, howpassed under the chin and over the head, ever, find that this second cork is not nethe lower jaw against the upper; bits of cessary, for there is not in this part so much cork being previously interposed between displacement as anteriorly. The cause of the teeth at each side. The same treatment this you will easily comprehend, when you has been adopted, you observe, in this wo consider the attachment of the depressor man’s case, where there is a double fracture, muscles. Let me make another remark to you. but you see it does not answer. You see how much she suffers. Now we shall give You might suppose that as a fractured jaw her great ease by adopting the proper mode is subject, to constant motion in speaking or of treating such cases. The plan is to in- deglutition, its reunion would not be easy. terpose a grooved cork at one side only, that The reverse is, however, in general, the is, at the side that is elevated, and then case, and I have often been surprised at the gently apply a bandage under the base of rapidity and satisfactory mode in which fracthe jaw, so as to raise as much as possible tures of this bone unite, even in cases the depressed side. Now let me explain to where from the carelessness and garrulity of you the principles of this practice. Look, the patient you might augur the worst. It first, at the state in which the bones are. is really very remarkable how admirably You remark that the portion of the jaw in- nature often works out her object in these terposed between the two fractures is much cases: yet, I have sometimes seen these depressed. This depression is caused, as 1 fractures remain ununited, and have then have already explained to you, by the con- had occasion to verify the remark of Boyer, traction of the depressing muscles, and by that it is surprising how little the disunion the weight of the unsupported fragment of atfects, after a time, either mastication or
by
jaw being pulled by
743
enunciation. Dr. Pbysick, of Philadelphia, interesting case ;
see
what
an
alteration in
succeeded in causing reunion in a case ofhis countenance; he has been in the hospital this kind, by the seton. I have also ob. only a few days : when first admitted, he served, on some occasions, union to have kept the ward awake all night, as I was intaken place with deformity. Hence, in formed, by his roaring out with the agonizing saying that these cases turn out well, al- pains of his bones, and particularly of his though little attention he paid to them, I am shins. He says he now rests most commaking only a general remark, and this fortably : his shins were, on his admission, must not to them.
induce you
to pay
a
uniformly swelled, from the knee to the ancle, that no defined prominences could be
lax attention so
Ward No. 8.-Oh, another fractured jaw ! felt along the tibia, and the soft parts coverwas this caused ? (The house-surgeon ing these bones were so tender, that he
How
she had been thrown down could not suffer the least pressure to be last night by a carriage in the street, that made on them. You see this is not now she was brought into the hospital in a state the case ; there are a number of projections of insensibility, and that it was supposed a or exostoses, to be felt, and although the wheel had passed over her head.") Although whole tibiae are still much larger than natural, there is, gentlemen, considerable swelling they feel vastly smaller than they did four and tenderness in the fractured side of the days ago. These changes in the form of his jaw, and about the parotid, there does not legs have resulted from the subsiding of the appear so much injury as would probably great tumefaction of the soft parts ; all tenhave been caused had a wheel passed over derness seems also to have subsided. You the jaw. The fracture may have been pro- see he allows me to make pressure all along duced by a simple fall on the jaw. Let us his shin. Again, look at his skin; you resee where the fracture is : you remark that mark that the groups of shining, scaly tuit is not in the situation of the fractures in bercles, which were scattered over the sur either of the other cases: it is a single frac- face of his body, and on his temples, have ture, and corresponds to the interval of the shrunk toa level with the surrounding skin; first and second incisor of the left side: you and two of those which had ulcerated, one on his back, and the other on his breast, also remark the nature of the the left or smaller portion is drawn out- have heated. Now what has caused all these wards, and the larger inwards and hack- remarkable changes in the space of four of £ wards. There is scarcely any perpendicular days ? Two drachms of the He has taken half a drachm of this displacement; this is owing to there being elevator muscles attached to each fragment. salt daily for the last four days. This is You remark that she has much more pain precisely one of those cases of syphilis in than the man in Ward No. 2, but less than which mercury acts as a poison; and this the woman in No. 4. You see I can easily man was half poisoned by mercury before replace the parts in their proper position, by he applied here. The employment of the hypulling outwards the left or smaller portion dydriodate of potash in such cases as this, of the jaw, and by pressing backwards the is the greatest improvement which has taken place in medical surgery in modern times. right portion. You may suppose, from the facility with This case makes the one hundred and which thefractures of the jaw in these three twenty-fourth of secondary syphilis which I I have so treated and carefully noted. Two cases have been detected, that their ciiag-I and a half have now passed since I nosis is always very easy; so it is if care be taken. You are, however, aware, that only commenced the investigation, and I have a few days since, a man who had been dis- collected as great a body of facts as have charged from prison, came to the Dispen- ever perhaps been collected, respecting the sary with an injury of his jaw, and when I treatment of any one chronic disease by a I am, I assure you, told him that his jaw was fractured, he re- particular remedy. arranging, whenever I have a moment to plied thet he had himself told Surgeon that his jaw was broke, but that he desired spare, these cases, and will commence, behim to go about his business, that there fore this month is out, to fulfil the promise, was nothing the matter with his jaw. You which I have long given you, of making see, therefore, that attention is requisite, them the subject of a series of clinical lecand upon some occasions considerable at- tures on syphilis. tention is necessary, to detect a fracture of the jaw ; for it may happen that there is no DISORGANIZATION OF TISSUES OF THE CA LF. displacement whatever, and a crepitus may be evident to the patient, when it can Ward No. 3.-There is a disease, gentlescarcely be detected by another person. men, in the upper and back part of the calf of this boy’s leg, to which I wish to direct HYDRIODATE 0 F POTASH IN SYPHILIS. your attention. You remark that there is Ward No. 6.—You are, I am sure, gentle- great and deeply extending hardness in the men, attending closely to this man’s most i part; that there is, what the common peo-
replied " that
displacement:
potash.
I years
-
hydriodate
744
pie call, a " flag ;" that the skin has a slight muscles of the trunk of the body, as It were, purplish colour. The leg is bent on the become roused into action, accompanied thigh, he cannot straighten it. There is with a deep and powerful inspiration, to be often much pain in this disease, particularly instantly succeeded by a loud, protracted, when the person stands or attempts to walk, but rather modulated shout. These efforts and unless treated in one particular way. it at pronunciation are evidently teasing, if is remarkably tedious, and often ends in the not actually painful, as she requires to be death of the hardened tissue, which falls out, frequently interrogated before making them. and leaves
a
hole
so
large sometimes,
that
you could bury an orange in it. We had a similar case in Ward No. 4, a short time ago, in the person of a woman. She had been treated before she came under my care, as this boy has been treated, with poultices, and leeches, and stupes, and was not benefited, nor has this boy been benefited by a similar treatment. This affection yields rapidly to mercury, and, as far as I know, to The woman was matemercury alone. rially relieved, just as soon as her gums were affected; and so will this boy be relieved as soon as the slightest action of mercury is perceptible. You see how poor and delicate a looking creature he is: you would say from his appearance that he had a very bad habit. The woman presented the same character of constitution, yet she bore the mercury well, and was extremely benefited by it. I may conjecture, but I do not pretend to say, what the disease is. I have told you its characters, and the manner in which you can cure it.
Has severe headache, as evinced by the frequent application of her hands to the forehead ; face flushed ; skin hot and dry, and
specks on the chest, of small-pox. Tongue coated with a brown fur; pulse about 100, not full; stomach irritable, rejecting the in. gesta, which is chiefly fluid, as there is con. siderable thirst ; bowels constipated. The there appear
a
few
probably the eruption
catamenia has been absent for these last two months. She was ordered a cooling mixture, with a common laxative powder. 22. The eruption of small-pox fully de., veloped, the pustules being distinct, and few in number. Irritability of stoand the appetite is mach has disappeared, improving. The thirst is less, pain in head diminished, but the state of lassitude persists, with a disinclination either to make the efforts at speaking, or to move herself in bed. Towards the evening there is a feverish access, and the nights are restless. preserved relaxed by cooling medi-
rather
Bowels cine.
26. The
articulation is
words, which
are
very
returning, the imperfectly spoken,
being wholly unintelligible so
CASE OF
SMALL-POX COMPLICATED WITH HYSTERIA. To the Editor
of THE
LANCET.
you consider the following case your truly independent and widely-circulated Journal, I shall feel much obliged by its insertion. I have the honour to be, Sir, your obedient servant, JOHN J. KELSO, M.D.
SIR,—If
merits
a
place in
Lisburn, Jan. 20, 1836. CASE.—J. F., Betat. 19, of
stout make enjoying up to a
and sanguine temperament, the present attack, for the most part, uninterrupted good health. Dec. 18, 1835, I saw her, and found that three or four days since she commenced ailing, but considering her
complaint
as
only
a
cold,
no
treatment
was
to her
to me, but not
immediate attendants.
Complains
in the lumbar region, shooting round to either groin, with a sense of heaviness in the hypogastrium. Face still keeps flushed, and the headache is occasionally violent. Tongue remains coated, but the appetite is unusually keen. Pulse about 90, rather weak. There is globus hystericus, and she cries and laughs alternately,-phenomena which set in a few days hack. Habeat emplastr. lyttæ nuchæ. 29. The pronunciation is becoming gradually more distinct and intelligible, the words being uttered at the top of an hysterical cry. There is present some debility, the keenness of her appetite. Sumat Tzyact. Lyttœ gtt. xv ter in die. Vesicat. parv. dextr. mammæ ; hip-baths. Jan. 5, 1836. The debility has increased. Bowels have been purged from a dose of the pil. aloet. co., which she had taken. The sense of hearing is remarkably acute, and the nervous system generally in a state of considerable excitement. Nights are still restless. Has been taking bitters, with carb. of iron, &c., for some time. 14. She is gradually, but rather slowly
of
severe
pain
notwithstanding
resorted to. She was lying on her right side, in a listless, stupid state, not caring to execute any motion, and apparently unconscious of what was passing around her. Has entirely lost the power of articulation, but convalescing; some hysterical symptoms appears quite sensible (in the intervals of still persisting. The catamenia has not frequent fits of delirium) of the nature of yet been restored. The tonic remedies &c. questions put to her, which she endeavours are to be continued. to respond to by efforts in which the whole Remarks.—The case just detailed I con-
HOSPITAL, DUBLIN.
CLINICAL REMARKS so very slight. Only the worst of stricture are admitted here. It BY is right that you should understand this, and you should be prepared to treat them DR. WALLACE. But there are a great many very difficult cases, for, indeed, many patients labouring under this disease have FRACTURES OF THE JA W. been bungled out of their lives " through JANUARY 19, 1836.-Ward No. 4.-Here, ignorance and inattention. This drawing represents mortification of the scrotum gentlemen, is a case of fractured jaw in a wofrom extravasation of urine. Patients do man ; let us compare it with the one in the not often survive under such mischief, or man in the ward No. 2 : the comparison will until the parts become thus disorganized; be useful. What are the relative situations of You saw some struggle through wonderfully, and ifthe fractures in these two cases ? incisions be not made, as they onght to be, that the man’s fracture was situated just at very early and very freely, the scrotum or the right side of the symphysis, that it passthe penis is often left uncovered and unpro- ed between the first and second incisors. And here let me remark, that fractures of tected. mention that occasionally the the jaw, although they are said to occur at passage ulcerates towards the corpus spon- the symphysis, never do take place in that giosum, and the urine is admitted into the situation, not really in it. This is what you vascular network, the penis becoming black might expect, when you reflect that the in consequence. It is not into the body of symphysis is much stronger than the part of the penis, but into the corpus spongiosum, the bone just connected with it, or at the that the infiltration occurs. The outer sur- side of it. You remark, that this woman has face of the glans, as you are aware, com- a fracture on the right side in precisely the municates freely with the spongy body, is, same situation as that of the man, but you in fact, a prolongation of that tissue. When see she has got a second fracture; the bone the glans becomes black, and sloughs, it is is broken on the left side also, immediately about one of the most alarming and fatal in front of its angle. This renders her case signs which we meet with, and many are fay more serious than that of the man. Obalarming enough in the disease. This is not serve what a difference there is between You saw that the man appeared to a very common occurrence, but Sir BEN- them. JAMIN BRODIE mentions, I think, two or suffer very little, and there was scarcely any three cases in which he noticed it, and in deformity. See how much the fragments all, the patients, I believe, perished. I have are here dispiaced; remark how this woseen the appearance also more than once, man appears to suffer, what agonizing pain but in one of the instances a fatal termina- she seems to experience about the fractured tion did not happen. The urine may in this angle, how the least motion of the head way be admitted at once into the blood, annoys her, and how she grasps her occiput and be returned by the veins into the with her hand to keep her head steady. mass of circulating fluid, and thus you can She discharges abundantly saliva from the account for the bad consequences which al- mouth, and is almost quite unable to artimost invariably follow, but still a fatal re- culate, whereas the man could speak very sult does not uniformly take place. distinctly. What is the cause of this great difference in these two cases ? I have often many of the distressing symptoms which you see in this woman, to arise when CURE OF ULCERS.—Dr. Cramer recom- the jaw was fractured far back; and I have mends for the treatment of ulcers, that a always supposed them to be owing to the piece of lint, imbued with the discharge, injury of the trunk of the sub-maxillary should be dipped in an impalpable powder of nerve, which you know enters the bone the nitrate of silver, and then reapplied to near its angle, and is, therefore, much exthe sore. This he repeats every day, or posed to injury in such cases as the present, every other day, and by his enforcing a quiet that is, when a fracture exists near the state of the member, he mentions his having angle. There is also another reason why succeeded in healing the most obstinate the double fracture in this woman should ulcers in a period of six or eight weeks. He produce much more serious consequences has likewise employed the same powder with than the single fracture in the man. The advantage to the granular conjunctiva.- depressors of the jaw are almost all attached to the middle fragment, while the elevaHeidelberg. Klinische Annal. tors are connected with the two posterior
danger is
cases
scientifically.
I should
observed
portions of the jaw; hence great displace..
742 ment must arise
the different parts of the jaw. You also remark what pain is given, their muscles in differ- whenever I attempt to raise this depressed ent directions. The middle portion is de- portion into contact with the upper jaw, or pressed, and the posterior portions are to a level with the other portion. You see raised, and this displacement is greatly faci- she will not allow this to be done; you can. litated by the direction of the fractures, not, in fact, by acting in this manner, either which is parallel to the line of direction in bring or retain the bones in their proper which the depressing muscles act, that is, situation, and even if no pain were produced, from above downwards, and from before the mechanism of the parts, and the direcbackwards. But in the man’s case, the tion in which the displacing muscles act, elevating muscles being connected with both would soon render your endeavonrs unavailfractured portions, the action of the de- ing. Well’ what should be done ? You pressors, which are connected with the large must, as I have said, depress the raised part, fragment, are greatly moderated, and hence you must bring it down to a level with the there is little displacement. broken fragment; and you do this by inter. Now how have these fractures been pro- posing a cork between the upper jaw and duced ? How has the fracture in the man the raised side, proportioning its thickness been produced? By a fall from a ladder on to the degree of displacement. You thus the chin. How has it been produced in the depress the raised side, and make it meet woman’s case ? By a blow on the left side of the depressed side. I shall now put in this the jaw. You can easily conceive, that the cork at the raised side. See what relief it mechanism of the forces which caused the affords ; I shall next pass this in at the other fractures in these two cases near the sym phy- side. You remark she cannot bear it; I sis was different, that is, the force did not must remove it. Now I shall apply a band. act in the one case, as it did in the other. age, as we did in the man’s case. This, In the man’s case, the tendency of the force then, is the mode of treating these fractures. was to straighten the jaw by pressing the In the one case, you apply a cork at both convexity of the chin inwards and back- sides; in the other, you apply it at one side wards, and the solution of continuity close only, and you see how admirably the differto the symphvsis commenced in the inside ence of treatment is suited to the two cases. of the jaw, and extended outwards. In I should mention to you, that it will some. this woman’s case, the force being applied times happen, that it will be useful in cases to the side of the jaw, the tendency of itsof double fracture to apply a second cork; action was to increase the natural curve of for example, in the present instance we the jaw, and the fracture near the symphysis might apply a cork between the posterior must have commenced externally, and passed teeth at the left side, not as it was applied inwards, and most probably the second between the upper jaw and the depressed fracture occurred subsequently to the first, fragment, but between the upper jaw and but by a continuance of the same force. the posterior and left fragment of the lower, What difference of treatment must be which is, as well as the right side of the jaw, adopted in these two cases ? You have ob- kept raised by the elevator muscles. This served that the man seems to be very com- would keep this portion of the jaw down to fortable under his injury; and all that has a level with the posterior end of the debeen done has been to retain, by a bandage pressed middle fragment. I generally, howpassed under the chin and over the head, ever, find that this second cork is not nethe lower jaw against the upper; bits of cessary, for there is not in this part so much cork being previously interposed between displacement as anteriorly. The cause of the teeth at each side. The same treatment this you will easily comprehend, when you has been adopted, you observe, in this wo consider the attachment of the depressor man’s case, where there is a double fracture, muscles. Let me make another remark to you. but you see it does not answer. You see how much she suffers. Now we shall give You might suppose that as a fractured jaw her great ease by adopting the proper mode is subject, to constant motion in speaking or of treating such cases. The plan is to in- deglutition, its reunion would not be easy. terpose a grooved cork at one side only, that The reverse is, however, in general, the is, at the side that is elevated, and then case, and I have often been surprised at the gently apply a bandage under the base of rapidity and satisfactory mode in which fracthe jaw, so as to raise as much as possible tures of this bone unite, even in cases the depressed side. Now let me explain to where from the carelessness and garrulity of you the principles of this practice. Look, the patient you might augur the worst. It first, at the state in which the bones are. is really very remarkable how admirably You remark that the portion of the jaw in- nature often works out her object in these terposed between the two fractures is much cases: yet, I have sometimes seen these depressed. This depression is caused, as 1 fractures remain ununited, and have then have already explained to you, by the con- had occasion to verify the remark of Boyer, traction of the depressing muscles, and by that it is surprising how little the disunion the weight of the unsupported fragment of atfects, after a time, either mastication or
by
jaw being pulled by
743
enunciation. Dr. Pbysick, of Philadelphia, interesting case ;
see
what
an
alteration in
succeeded in causing reunion in a case ofhis countenance; he has been in the hospital this kind, by the seton. I have also ob. only a few days : when first admitted, he served, on some occasions, union to have kept the ward awake all night, as I was intaken place with deformity. Hence, in formed, by his roaring out with the agonizing saying that these cases turn out well, al- pains of his bones, and particularly of his though little attention he paid to them, I am shins. He says he now rests most commaking only a general remark, and this fortably : his shins were, on his admission, must not to them.
induce you
to pay
a
uniformly swelled, from the knee to the ancle, that no defined prominences could be
lax attention so
Ward No. 8.-Oh, another fractured jaw ! felt along the tibia, and the soft parts coverwas this caused ? (The house-surgeon ing these bones were so tender, that he
How
she had been thrown down could not suffer the least pressure to be last night by a carriage in the street, that made on them. You see this is not now she was brought into the hospital in a state the case ; there are a number of projections of insensibility, and that it was supposed a or exostoses, to be felt, and although the wheel had passed over her head.") Although whole tibiae are still much larger than natural, there is, gentlemen, considerable swelling they feel vastly smaller than they did four and tenderness in the fractured side of the days ago. These changes in the form of his jaw, and about the parotid, there does not legs have resulted from the subsiding of the appear so much injury as would probably great tumefaction of the soft parts ; all tenhave been caused had a wheel passed over derness seems also to have subsided. You the jaw. The fracture may have been pro- see he allows me to make pressure all along duced by a simple fall on the jaw. Let us his shin. Again, look at his skin; you resee where the fracture is : you remark that mark that the groups of shining, scaly tuit is not in the situation of the fractures in bercles, which were scattered over the sur either of the other cases: it is a single frac- face of his body, and on his temples, have ture, and corresponds to the interval of the shrunk toa level with the surrounding skin; first and second incisor of the left side: you and two of those which had ulcerated, one on his back, and the other on his breast, also remark the nature of the the left or smaller portion is drawn out- have heated. Now what has caused all these wards, and the larger inwards and hack- remarkable changes in the space of four of £ wards. There is scarcely any perpendicular days ? Two drachms of the He has taken half a drachm of this displacement; this is owing to there being elevator muscles attached to each fragment. salt daily for the last four days. This is You remark that she has much more pain precisely one of those cases of syphilis in than the man in Ward No. 2, but less than which mercury acts as a poison; and this the woman in No. 4. You see I can easily man was half poisoned by mercury before replace the parts in their proper position, by he applied here. The employment of the hypulling outwards the left or smaller portion dydriodate of potash in such cases as this, of the jaw, and by pressing backwards the is the greatest improvement which has taken place in medical surgery in modern times. right portion. You may suppose, from the facility with This case makes the one hundred and which thefractures of the jaw in these three twenty-fourth of secondary syphilis which I I have so treated and carefully noted. Two cases have been detected, that their ciiag-I and a half have now passed since I nosis is always very easy; so it is if care be taken. You are, however, aware, that only commenced the investigation, and I have a few days since, a man who had been dis- collected as great a body of facts as have charged from prison, came to the Dispen- ever perhaps been collected, respecting the sary with an injury of his jaw, and when I treatment of any one chronic disease by a I am, I assure you, told him that his jaw was fractured, he re- particular remedy. arranging, whenever I have a moment to plied thet he had himself told Surgeon that his jaw was broke, but that he desired spare, these cases, and will commence, behim to go about his business, that there fore this month is out, to fulfil the promise, was nothing the matter with his jaw. You which I have long given you, of making see, therefore, that attention is requisite, them the subject of a series of clinical lecand upon some occasions considerable at- tures on syphilis. tention is necessary, to detect a fracture of the jaw ; for it may happen that there is no DISORGANIZATION OF TISSUES OF THE CA LF. displacement whatever, and a crepitus may be evident to the patient, when it can Ward No. 3.-There is a disease, gentlescarcely be detected by another person. men, in the upper and back part of the calf of this boy’s leg, to which I wish to direct HYDRIODATE 0 F POTASH IN SYPHILIS. your attention. You remark that there is Ward No. 6.—You are, I am sure, gentle- great and deeply extending hardness in the men, attending closely to this man’s most i part; that there is, what the common peo-
replied " that
displacement:
potash.
I years
-
hydriodate
744
pie call, a " flag ;" that the skin has a slight muscles of the trunk of the body, as It were, purplish colour. The leg is bent on the become roused into action, accompanied thigh, he cannot straighten it. There is with a deep and powerful inspiration, to be often much pain in this disease, particularly instantly succeeded by a loud, protracted, when the person stands or attempts to walk, but rather modulated shout. These efforts and unless treated in one particular way. it at pronunciation are evidently teasing, if is remarkably tedious, and often ends in the not actually painful, as she requires to be death of the hardened tissue, which falls out, frequently interrogated before making them. and leaves
a
hole
so
large sometimes,
that
you could bury an orange in it. We had a similar case in Ward No. 4, a short time ago, in the person of a woman. She had been treated before she came under my care, as this boy has been treated, with poultices, and leeches, and stupes, and was not benefited, nor has this boy been benefited by a similar treatment. This affection yields rapidly to mercury, and, as far as I know, to The woman was matemercury alone. rially relieved, just as soon as her gums were affected; and so will this boy be relieved as soon as the slightest action of mercury is perceptible. You see how poor and delicate a looking creature he is: you would say from his appearance that he had a very bad habit. The woman presented the same character of constitution, yet she bore the mercury well, and was extremely benefited by it. I may conjecture, but I do not pretend to say, what the disease is. I have told you its characters, and the manner in which you can cure it.
Has severe headache, as evinced by the frequent application of her hands to the forehead ; face flushed ; skin hot and dry, and
specks on the chest, of small-pox. Tongue coated with a brown fur; pulse about 100, not full; stomach irritable, rejecting the in. gesta, which is chiefly fluid, as there is con. siderable thirst ; bowels constipated. The there appear
a
few
probably the eruption
catamenia has been absent for these last two months. She was ordered a cooling mixture, with a common laxative powder. 22. The eruption of small-pox fully de., veloped, the pustules being distinct, and few in number. Irritability of stoand the appetite is mach has disappeared, improving. The thirst is less, pain in head diminished, but the state of lassitude persists, with a disinclination either to make the efforts at speaking, or to move herself in bed. Towards the evening there is a feverish access, and the nights are restless. preserved relaxed by cooling medi-
rather
Bowels cine.
26. The
articulation is
words, which
are
very
returning, the imperfectly spoken,
being wholly unintelligible so
CASE OF
SMALL-POX COMPLICATED WITH HYSTERIA. To the Editor
of THE
LANCET.
you consider the following case your truly independent and widely-circulated Journal, I shall feel much obliged by its insertion. I have the honour to be, Sir, your obedient servant, JOHN J. KELSO, M.D.
SIR,—If
merits
a
place in
Lisburn, Jan. 20, 1836. CASE.—J. F., Betat. 19, of
stout make enjoying up to a
and sanguine temperament, the present attack, for the most part, uninterrupted good health. Dec. 18, 1835, I saw her, and found that three or four days since she commenced ailing, but considering her
complaint
as
only
a
cold,
no
treatment
was
to her
to me, but not
immediate attendants.
Complains
in the lumbar region, shooting round to either groin, with a sense of heaviness in the hypogastrium. Face still keeps flushed, and the headache is occasionally violent. Tongue remains coated, but the appetite is unusually keen. Pulse about 90, rather weak. There is globus hystericus, and she cries and laughs alternately,-phenomena which set in a few days hack. Habeat emplastr. lyttæ nuchæ. 29. The pronunciation is becoming gradually more distinct and intelligible, the words being uttered at the top of an hysterical cry. There is present some debility, the keenness of her appetite. Sumat Tzyact. Lyttœ gtt. xv ter in die. Vesicat. parv. dextr. mammæ ; hip-baths. Jan. 5, 1836. The debility has increased. Bowels have been purged from a dose of the pil. aloet. co., which she had taken. The sense of hearing is remarkably acute, and the nervous system generally in a state of considerable excitement. Nights are still restless. Has been taking bitters, with carb. of iron, &c., for some time. 14. She is gradually, but rather slowly
of
severe
pain
notwithstanding
resorted to. She was lying on her right side, in a listless, stupid state, not caring to execute any motion, and apparently unconscious of what was passing around her. Has entirely lost the power of articulation, but convalescing; some hysterical symptoms appears quite sensible (in the intervals of still persisting. The catamenia has not frequent fits of delirium) of the nature of yet been restored. The tonic remedies &c. questions put to her, which she endeavours are to be continued. to respond to by efforts in which the whole Remarks.—The case just detailed I con-