KASHMIR HOSPITAL.

870 cut ends well into

apposition.

The wound

was

dressed with

carbolic oil and carbolised tow, and the limb placed on splints in a swins cage. On April 29th there was a good deal of swelling and pain, with temperature 103°, necessitating the removal and renewal of the dressings. On May 2nd the temperature was 98° in the morning. There was a good deal of discharge and the wound was redressed. Temperature in the evening 1«1 ’3°. On the 3rd the temperature was 101 *2°. An erysipelatous blush surrounded the wound and extended up the leg. The skin was puffy. Incisions were made releasing some pus. i Poultices were applied. The temperature ranged between 99° and 100° for five days, and on May 8th the blush had quite disappeared. The wound was dressed again with carbolic oil. On the 9th the temperature was 103°. The puffiness of the wound reappeared. Poultices were again ordered. Two days later the patient complained of sore-throat, tenderness behind the ramus of the jaw, and on the 12th she was unable to separate the teeth more than an inch. Temperature 99°. Chloral hydrate was given in ten-grain doses every four hours. On the 13th she could not open her mouth as much as before. There was stiffness of the neck. Temperature 100°. On the 14th the jaw was about the same. But during the night she woke several times suddenly and bit her tongue. I She complained of stiffness of the upper arm and of her leg, and of continually jumping. There was no spasm of abdominal muscles. Temperature 99°. , After consultation, amputation was decided on, and as the integument below the knee was sufficiently sound, that ’, joint was spared. Chloral hydrate was repeated. On the 15th she had a rather restless night, every sound ’, made her start ; but next morning the stiffness of the neck i and arm was decidedly less ; and though the patient was unable to open her mouth quite so much as on the previous day, she said it felt less stiff and more comfortable. Temperature 103°. On the 16th she had slept well. The stump was dressed ; the skin had sloughed over the end of the bone. Patient felt generally better. Two grains of quinine were given every four hours. Evening temperature 104’30. The stiffness of jaw was worse again, and the patient complained of pain in the left shoulder. There was slight opisthotonos for the first time. She complained of the leg jumping. Could not open her jaw more than a quarter of an inch. Ordered curare to be hypodermically injected, and to be repeated at intervals of two or three hours at the discretion of the house-surgeon. This was done four times without relief. At midnight she had a morphia injection. She slept at intervals after the morphia, and on the following morning she felt better. The stump discharged freely. Temperature 100°. Morphia injection four times during the day. On the 18th she had had a very restless night. The nurse stated that at 4 A.M. she had a "kind of fit," consisting of spasm of all the muscles. The face became very blue. This lasted some niinates. She was very desponding and much exhaustei. Temperature 102°. Nutrient enematawith chloral hydrateand fifteen drops of thesedative solution of opium were given every four hours. She slept well after the first, and next morning the temperature was 98°. The slough was

separating.

On the 21’!t she had slept well. The slough came away. The wound was dressed again with carbolic oil. The ends of the bones were exposed. She varied from day to day, but on the whole she improved. On the 27th a weight and pulley were applied to the skin above the stump in order to draw it, if possible, more over the end of the bone. The stump was a long time in cicatrising, but eventually it quite healed, and the patient left the infirmary on Aug. 3rd. The diet was liberal throughout. On examining the leg after its removal a spiculum of bone was found pressing on the posterior tibial nerve, which no doubt was the fons et oriqo of the tetanus. On Sept. 19th, 1881, MI"s A- called to show Mr. Walsh what an excellent artificial beg had been supplied to her by Mr. Gray, for although the stump was necessarily short and the head of the fibula was drawn out by the violent tetanic spasm of the biceps, forming an ugly stump, she could bend the knee well, and walk satisfactorily.

KASHMIR HOSPITAL. SIX

CASES OF SYPHILITIC NECROSIS OF THE JAW ; REMOVAL OF SEQUESTRA, IN THREE CASES BY INCISION FROM WITHOUT, AND IN THREE BY OPERATION INSIDE THE MOUTH ; RECOVERY.

(Under the care of Mr.

E. DOWNES.)

CASE l. -A young man from Yarkand, who was literally from the pus which he had daily to swallow from necrosis of the whole bone of the lower jaw, from one condyle to the other. Nothing but removal of the entire bone seemed likely to do any good. This was done in July, 1877, by an external incision. The operation was a formidable one in which the able assistance of Drs. Williams and Ross of the Indian Medical Service was both acceptable and extremely serviceable. The patient was placed in an arm-chair, and chloroform was given. An incision was then made from a point opposite the condyle on the left side to the angle, along the bone to the symphysis and from thence to the corresponding spot on the right side. There had been so much inflammatory action that the facial arteries were obliterated and required no ligature. The flaps were turned up, and it was then found that a good deal of reparative action had been going on. The operation was completed by removing the whole bone, temporal processes and articulations. There was no ieal difficulty about the operation, and, thanks to the excellent assistants, was speedily completed. Dr. Williams put in the sutures, using by preference horsehair for the purpose. The patient had to be fed on milk for about a fortnight, but during that time he never suffered much pain, and he did not have a bad symptom. The sutures held firmly, and the outside wound healed by first intention. There was some secretion of pus in the inside of the mouth as the cavity left by the jaw healed, but it was much less in quantity and less offensive than that formed before the operation. The patient’s health improved from a day or two after the operation, and he steadily gained strength till he left the hospital, which was little more than a month after the operation. At that time few people would have suspected that his jaw had been removed, had it not been he adduced the "ocular proof"in the old jaw which the patient carried away to his native land, wrapped up in a, piece of newspaper. CASES 2 and 3.-The success of the above case led Mr. Downes to attempt the removal of half of the jaw on two occasions in 1878. One case was that of a middle-aged man, a Hindoo. In this case the discharge of pu, was excessive, and was poisoning him. He was first seen with Dr. Currie, the Civil Surgeon, who thought that his health was so much impaired that operation was not advisable. However, it was at length decided to give him the chance of operation, and Dr. Currie kindly assisted in the operation. The other case was of a woman, also middle-aged, and a Hindoo. It is not necessary to descdbe the operation very minutely. In both cases the disease, though very extensive, was limited to one side. The operation was the same as that done in Case 1, except that the incision was limited to one side, and the bone was cut through a little to the side of the symphysis with a Hey’s saw and bone forceps. In the case of the man (Case 2) the external wound healed without difficulty ; in the case of the woman (Cise 3) a fistula formed which gave great trouble, but eventually healed. In both these cases, one or two incisor teeth on the other side became loose, and had to be removed. In the case of the man, a piece of bone remained bare some months afterwards, and probably has loosened and come away without much trouble ; but he has not been seen for more than a year. In both these cases a great deformity resulted. The face was very much drawn to the side from which the bone was removed. Though both these lives were saved by the operation, the result was not quite satisfactory in either case, and contrasted very unfavourably with that of the three cases recorded below, in which about half the jaw was removed from the inside of the mouth. CASES 4, 5, and 6.-All these three cases were seen in 1879 and were tolerably young men, and in each case the disease was extensive, though quite confined to one side, commencing about the first bicuspid tooth and extending back nearly to the articulation, though in all three cases the

dying

871 joint was unaffected. In one case the temporal process was liver, but less marked than in the swollen part. The heart diseased, but not in the other two ; the bone was loosened murmurs were not heard over the liver region ; the vessels in all three cases opposite the first bicuspid tooth, but the were not distended; no ascites ; no anasarca. The nature disease was still progressing in the other direction. In one of this case is an interesting problem, as the pulsation was case the patient applied to have his last molar tooth ex- hardly so general as in cases of pulsating liver. On the tracted. It was only while this was being done the full other hand, was it an aneurism of the hepatic artery extent of the disease was discovered. The state of affairs was explained to the patient, and with his sanction chloroform was given, and the operation completed. The operation in all three cases was very similar. The patients were placed under chloroform, in the recumbent position, and after removal of the teeth on the diseased side the periosteum from the bone was separated as far back as possible from the line of demarcation, near the bicuspid tooth, backwards. There was a little haemorrhage. The denuded bone was then seized with lion forceps, and in each case the bone broke at once near the angle. The end of the bone having again been seized with the lion forcepsi was pulled out as far as possible, and the periosteum was separated a little further. Thus, in all three cases, the whole of the diseased portion of the bone was removed, including the temporal process and articulation. Considerable force had to be used in one case in order to tear asunder the tendon of the temporal muscle. In another case the muscular fibres of the internal pterygoid were ruptured. No injury was done by this seeming violence, and there was no troublesome hsemorrhage. The patients complained of very little pain afterwards-in were very pleased at getting rid of their diseased fact, they jaw, and the loathsome discharge attending it. For a few days there was a good deal of swelling, but there was not a very great discharge cf pus, and in less than a fortnight the wound was healed and new bone had commenced to form ; the healing process continued satisfactorily, and all three patients left the hospital in about three weeks with very

or

a

collection of fluid in the liver, with transmitted

pulsation ?-Dr. MAHOMED remarked that one other alternative explanation was atrophy and great weakening of the diaphragm. The man’s belly had been distended, and his diaphragm had for a long time been rendered practically useless. He seemed to breathe entirely its expansion the belly receded ; with his chest, and possibly, therefore, the heart might cause pulsation in the

during

liver the want of tension of the diaphragm.—Dr. WILKS asked Dr. Taylor if he had not published cases of heart disease with reflux of blood and true hepatic pulsation.-Dr. TAYLOR replied that he had, but was not able to say that this was such a case.-Dr. POWELL asked if the man had had marked cyanosis.-Dr. WEST said be had not. - Dr. D. POWELL said he always expected marked hepatic pulsation in all cases of extreme aortic regurgitation. He could not understand that if he had a quite flaccid diaphragm, why the dyspncea was not more urgent.-Dr. WILKS said there were two questions raised, whether there really was such a thing as pulsating liver, and whether this was a case.-Dr. S. WEST said the pulsation in the liver was systolic. He could not accept Dr. Mahomed’s suggestion as a sufficient explanation. The pulsation was more marked than it had ever been before, although the cyanosis was less. Dr. S. WEST also showed a specimen of Tubal Pregnancy. On June 30th, fourteen days before admission to hospital, a woman complained of pain in the left side of her belly, which continued till death. On July 9th there was little deformity. hsemorrhage from the vagina; on July 13th she was admitted Remarks by Mr. DOWNES.—Kashmir is a country whose into hospital, suffering from profound collapse, and she died inhabitants have all, or nearly all, become syphilised, and, the same evening. Post mortem the abdomen was found as a rule, no antidote is taken to counteract the poison of the to be filled with fluid blood and large clots. A tumour, disease. The consequence is that syphilis is very often seen the size of an orange, was attached to the right side of in the worst forms in the tertiary stage. Diseases of the the brim of the pelvis, which proved to be a right tubal bones are met with frequently, and among the bones impli- pregnancy. The uterus was enlarged with a thickened cated the lower jaw is not uncommonly affected. Many bad mucous membrane. The right ovary was distinct from but cases of necrosis of the lower jaw occur, and on several adherent to the tumour. The placenta was attached to the occasions I have removed pieces of dead bone with good pelvis and rectum, and had ruptured behind and caused death. success. I have once had to remove the whole of the lower The right Fallopian tube was impervious. The left tube was jaw, and in five cases I have removed it on one side, and in pervious, and the left ovary contained a corpus luteum. The no case did a patient die. The chief object of the above foetus was about three months old. The woman had prerecord is to compare the two methods by which the bone viously borne two living children. The special points of may be removed-viz., from the outside, as, I believe, is interest were the enlarged uterus and deciduous membrane commonly done, or from the inside, as was advocated so lining the uterus, the place of attachment of the placenta, and strongly by the late Mr. Maunder. It will be seen that I of its rupture, and the corpus luteum in the ovary opposite have been forced to accept the latter as the better operation. to the pregnant tube.-The PRESIDENT asked how this last fact was explained ; had the ovum crossed the uterine cavity, or did it pass across the pelvic cavity ?-Dr. WILTSHIRE said that other cases were on record in which an embryo had developed in a tube with a blocked outer end, in which evidently the ovum must have crossed the uterus from the In St. Mary’s Hospital Museum was a opposite ovary. PATHOLOGICAL SOCIETY OF LONDON. specimen of double tubal pregnancy; at the distal end of the left tube an obsolescent mass was found containing rePulsating Liver. Extra-uterine Pregnancy. - Rickety mains of a foetus, and nearer the uterus a second tubal Deformity of Thorax, with Spontaneous Fracture of Ribs. cyst which had ruptured and caused death. It is very rare —Aneurism of Aorta.—Hypertrophied Toe-nail.—Aortic fur the decidual membrane in these cases, which is always Stenosis.—Bronchocele. developed, to be thrown off; but if it be, it greatly helps He had seen a case with symptoms THE ordinary meeting of the Pathological Society was in the diagnosis. like those of Dr. West’s case, where the membrane had held on Tuesday, Nov. 15th, the President, Dr. Wilks, been discharged ; afterwards foetal bones were passed per F.R.S., in the chair. Several specimens of interest were rectum. exhibited. One marked feature of the meetings this session Mr. R. W. PARKER showed a case of Rickety Deformity thus far has been a diminution in the number of " card of Thorax, with Spontaneous Fracture of Ribs, taken from a child aged twelve months, who had died in the East London specimens. Dr. S. WEST showed a man, aged twenty-one, a boot- Hospital for Children of bronchial catarrh and lung collapse. was twofold : (1) The ordinary depression, finisher by trade. He had severe heart disease following The deformity external to the costo-chondral junction; and immediately rheumatic fever. In 1879 his belly and feet began to swell ; (2) a bending of the rib at the point of greatest convexity in a few months he was tapped thrice for ascites. Later on (the mid-point of the rib proper). In several of the ribs, he was tapped twice while in hospital, and then recovered. this bending amounted to distinct fracture ; a,nd as there Two months after leaving the hospital he returned and was no history of violence, the fractures were considered to tapping. He then had pain at the epigastrium, be spontaneous, such as are known to occur in cases of welland after tapping, an area of pulsation just to the right of marked rickets. There were, however, no appearances or the middle liue at the epigastrium was noticed; this was symptoms pointing to such a condition during life ; and about three inches in diameter. The heart and liver were he thought it possible, therefore, that the actual fracboth enlarged. The pulsation was general over the wholeture might have taken place at the moment of

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