222

21st, 1882. Three years before some dust was thrown intothe left eye; a slight attack of inflammation followed, forwhich he was treated at the Royal London OphthalmicHospital. He did not notice any failure of vision of the lefteye till on one occasion the right eye was covered, when itwas found that the left had only perception of shadows.The eye entirely recovered, and two years before admissioninto Guy’s his sight was as perfect as ever. About a yearbefore admission he began to notice floating opacities in botheyes ; in sunlight the opacities appeared red. (Patient nowremembers that about five years ago he suffered in a similarmanner, but quite recovered.) The floating opacity in theleft eye soon became fixed and obscured vision so much thatonly perception of shadows remained. The patient attendedamongst the out-patients in November, 1881. At that timevision was the same as on admission-i. e., right eye readsJaeger No. 1 at one foot and 6-6ths, when opacities had floatedout of the way. Left eye had perception of shadows only.The ophthalmoscopic appearances were : right eye, darkfloating opacities in vitreous, settling into a dark mass atthe lower part of fundus; left eye, yellowish reflection fromwhole of fundus ; retina appeared to be detached. Thepatient’s general health was good. He did not suffer fromconstipation.-22nd : Hypodermic injection of one-sixth of agrain of nitrate of pilocarpine ; injection followed by profusesweating.—25th : The quantity of pilocarpine increased toa quarter of a grain ; on the 28th to half a grain; on the29th the patient complained of headache. As there was noalteration in the condition of the eyes, the injection wasdiscontinued. He was kept in bed during the time that hewas treated by the injection.July 18th :-The patient is still under treatment. For the

last month he has been rubbing mercurial ointment into thetemple. The right eye varies from time to time as freshhaemorrhages occur; but when’there has been no bleedingfor about a fortnight, vision is as good as on admission.The left eye remains quite blind. ,

Remarks.—It appears from these three cases that if pilo-carpine does any good it does it within a week, and that itis useless to continue the injections longer. Its effects donot last. Cases 1 and 2 were decidedly improved, but soonrelapsed. The patients objected so much to the treatmentthat they were not pressed to try it again ; possibly the sameamount of improvement would have taken place had theinjections been repeated after some weeks’ discontinuance.Case 3 is a. good instance of a class of cases which unfortu-nately are not very uncommon-i.e., repeated bleedings intothe vitreous humour occurring in young adult males, againstwhich treatment seems almost powerless, and which endsooner or later in total blindness.

THE QUEEN’S HOSPITAL, BIRMINGHAM.SUBPERIOSTEAL RESECTION OF HIP-JOINT FOR CHRONIC

HIP DISEASE ; FRACTURE OF FEMUR DURINGOPERATION; CURE; REMARKS.

(Under the care of Mr. WEST.)JAMES P-, aged thirteen, was admitted into the

Queen’s Hospital on Oct. 2nd, 1881, in a feeble ansemic

state, suffering from advanced hip disease on the left side.The limb was shortened two inches, adducted, and the kneeflexed, very painful when moved; there was evident mus-cular atrophy. A sinus existed over the great trochanterleading to carious bone, and an abscess was forming overthe anterior superior iliac spine. The disease began sixmonths previously (as he states), from carrying heavy basketsof goods for a grocer. He had previously been in hospital forthree months, and relieved by rest and extension. The sametreatment was employed, good diet, cod-liver oil, and syrupof iodide of iron being also given. No improvement, how-ever, resulted, but the hectic symptoms and exhaustionrather increased. Mr. West on Dec. 3rd resected thejoint by a single straight incision, preserving as much aspossible the periosteum. In turning the head of the femur

’’

through the skin wound considerable force was required to Ibreak down the adhesions which had formed between thefemur and the dorsum ilii, close to the acetabulum, andwhile an assistant was using the lower end of the femur asa lever, with a view of turning the head out of its new socket,the femur was broken about the middle. This accident at thetime rendered the excision of the head of the femur rather

difficult; but, strange to say, it did not militate against theultimate success of the case. The operation was performedantiseptically minus the spray, and the limb was put upwith an extension apparatus after an interrupted splint hadbeen applied along its outer side.On Jan. 4th, 1882, the antiseptic dressing was discon.

tinned and the wound dressed with sulphate of copper lotion.On Feb. 2nd, a starched case was applied to the limb.

The fracture seemed to have united, and the line of incisionwas healed except at one or two points.On March 6th a Thomas’s splint was applied, and the

patient was sent to the Convalescent Home for Children atSolihull, where he remained till the beginning of June,steadily improving in health and gaining increased power inthe thigh. The limb is now only an inch shorter than thesound limb, although it was two inches less before theoperation. There is much deposit of new bone, and thesite of the fracture can now scarcely be made out.

Remarks.—Professor Sayre, in his excellent pracsicalwork on Orthopædic Surgery (p. 290), alludes to the occur.rence of fracture of the femur in the operation of resectionof the hip, if care and gentleness are not employed in usingthe femur as a lever. This case is a further proof of thenecessity for such care in dealing with bone that is weak-ened by disease, but it aho teaches us that when fracturedoes unfortunately occur, the result, both as to length andstrength of the limb, may be all that could be desired. Itconfirms the views enunciated in THE LANCET annotation ofJuly 1st, 1882, on "Lengthening of the Femur after Divi.sion," à propos of the specimen shown by Dr. Moore atthe recent meeting of the American Medical Asssociation,in which "an interval between the fragments of more thanan inch in length was completely filled with new bone."

BOOTLE BOROUGH HOSPITAL.SEVERE INJURY TO RIGHT FOOT; NECROSIS OF METATARSAL

BONES; OPERATION; CURE; REMARKS.

(Under the care of Dr. C. SWABY-SMITH.)FOR the following notes we are indebted to Mr. Chas. A.

McLean, M.B., house-surgeon.J. H-, aged forty-three, seaman, was admitted on

Dec. 29th, 1881, suffering from an injury to his right foot,which he sustained while engaged in one of the Cunardboats repairing the sails on one of the masts, from which hefell. He was attended by the ship’s doctor previous toadmission.On examination there was found what appeared to be

fracture of the metatarsal bones. Sinuses had formed onthe inner and outer aspects of the foot, which altogetherpresented disorganisation of its constituent joints and bones.Dr. Swaby-Smith made a careful exploration of the parts,and found necrosed bone, more especially in the metatarsalaspect of the great toe. He left the parts alone for twodays, when, on re-examination, the probe revealed disin-tegrated bony structure, which ended in the formation ofpus, and its consequent extravasation along the musclesand synovial structures. The patient was anæsthetised(chloroform having been administered), and Dr. Smith madean incision over the metatarsal joint of the great toe, andremoved about half of this bone. The subsequent localtreatment consisted in the application of carbolic oiled(1 in 10) lint to the part, with pressure on the plantar aspectof the foot, and careful attention to cleanliness, the foothaving been bandaged from the toes upwards. The outeraspect of the foot, which presented a sinus, and from whichfragments of necrosed bone which had gradually workedtheir way to the surface had been removed, steadily showedsigns of repair. Sinuses had also formed between the greatand second toes, and between the fourth and fifth. From.these pus came at first in considerable quantity, origi-nating from the plantar aspect of the foot ; for whenpressure was applied here the matter was obviously findingan exit in the regions already mentioned, and also over thesinuses which existed in the metatarsal bones of the greatand small toes on the dorsum of the foot. The dressings ofcarbolic oiled lint were, a fortnight subsequent to operative eprocedures, changed, nitric acid lotion (half a drachm ineight ounces of water) having been substituted. His dieton admission was ordinary ; but he got milk and beef-teadiet on Jan. 24th, 1882.