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o’clock noon, in a state of complete unconsciousness,with severe vomiting and purging, the stools being of therice-water character. It appears that he had been doing hiswork up till 9 A.M., and it was while cutting grass in thesun that he first fell ill. When seen the following morning(August 21st) his state was as follows :-Features pinched;surface quite cold to the touch. Tongue dry, with slightbrown fur. Is now quite sensible, and able to get out ofbed. Pulse 118, very weak; respiration 32; temperature99 2°. Passed a little urine yesterday evening. On passinga catheter the bladder is found to be quite empty. Is still

purged, the stools being of the consistence of whey, dirtylight brown in colour, free from smell, with floatingflocculi. Voice is now fairly strong.-7.30 P. M.: Surface stillfeels cold. Temperature 99’4°; pulse 120, very feeble.Abdomen tense and tympanitic. No urine in bladder. Haspassed three stools since the morning, of thick consistence,taintly yellow colour, and slightly bilious odour.August 22nd.-Lies in a drowsy state. Pulse 120; re-

spiration 24; temperature 100.1°. Has passed four stoolsduring the night, of distinctly yellow colour. Urine stillsuppressed. He gradually became comatose, and died at6 P.M., after a slight convulsive attack.Autopsy, half an hour after death.-The chief morbid

appearances observed were : Firm pleural adhesions on bothsides of the thorax; extreme congestion of both lungs ; theright ventricle distended with fluid black blood ; walls ofthe left ventricle hypertrophied ; well-marked atheroma ofaorta. Kidneys weighed 4 oz. and 6 oz. 7 drs. respectively ;both were diseased, the surface of each being uneven fromthe presence of numerous depressions, in the vicinity ofwhich were several small projecting nodules ; capsuleadherent in places; surface of section pale and bloodless;no distinction between central and cortical portions; thepyramidal portion was ior two-thirds of its extent occupiedby a deposit of a light yellow colour and firm consistence,occurring in isolated masses of circular shape, and varyingin size from that of a millet-seed to that of a pea. With theexception of decided vascularity of the mucous membrane ofthe large bowel, the intestines were healthy. Bladderfirmly contracted and empty.

Remarks.—At the time of the occurrence of this case anoutbreak of cholera was not unlikely, as cases had beenreported from some stations close by. The sudden occurrenceof the symptoms of unconsciousness, coldness of surface,feebleness of voice, vomiting, purging, the stools being ofthe rice-water character, and finally the suppression of urine,might have justified the diagnosis of malignant cholera,and in the absence of an autopsy the case would mostprobably have been reported as such. The examination,however, revealed a hopelessly disorganised pair of kidneys,and justified the conclusion that all the symptoms were dueto uræmia. It will, therefore, be well to bear in mindthe possibility of cholera-like symptoms being due to thediseased kidneys. It may be added that, contrary to ex-pectation, no outbreak of cholera took place at the stationwhere the subject of these notes died.Watton.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

ST. THOMAS’S HOSPITAL.TRAUMATIC NEUROMA OF ULNAR NERVE, WITH LOSS OF

POWER OF PARTS SUPPLIED.

(Under the care of Mr. SYDNEY JONES.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborumet disgectionum historias, tum aliorum tum proprias collectas habere, etlater se comparare.—MORGAGNI De Sed. et Oau8. Morb., lib. iv. Procemium.

E. A-, aged ten, was admitted on March 10th, 1882.Twelve months before she had fallen on to a window, andwounded her left arm above the elbow on the inner side.The wound was sutured, and healed in a month’s time, buta tender spot remained in the centre.On admission she complained of a tender place above the

left elbow, and on examination of this there was found to be

two inches above and a little posterior to the internal condyle,a scar about an inch and a half in length, running down-wards and backwards ; posteriorly to this there was anotherabout three-quarters of an inch long. Beneath the principalcicatrix there was a very tender swelling in the course ofthe ulnar nerve, about the size of a horsebean, and present-ing the character of a neuroma. Attached to this and alittle below (a quarter of an inch) was a much smaller swell-ing having the same character. The left forearm was notso well developed as the right, this being most marked in theflexor and the inner sides ; there was loss of sensation alongthe ulnar side of the hand, the whole of the little finger, andulnar side of ring-finger. The movements of adduction ofthe hand and apposing of the little finger and thumb were im-perfect, and she was unable to adduct or abduct the fingers.The muscles of the inner side of the hand and between themetacarpal bones were much wasted.On March 18th, the patient being under the influence of

ether, Mr. Sydney Jones made an incision about threeinches in length over the neuroma and in the course of theulnar nerve, and another at right angles to this. On dissect-ing down, the two swellings were found to be connected withthe ends of the divided nerve, which were about two inchesapart, a small fibrous cord connecting the two. The bulbousenlargements were removed. Both ends were stretched, theupper end to much greater extent and more easily than thelower, and were united together by means of three catgutligatures. It wa3 difficult to retain them in position onaccount of the tension. This was avoided by putting theelbow in a straight position. A drainage-tube was placed inthe wound, which was closed by catgut sutures, and the limb,placed in a straight position, was encased in an antero-posterior plaster-of-Ptris splint. The operation was con-ducted antiseptieally.—19th : In great pain all day ; paindescribed as of a jumping character. Temperature in themorning 104’2°, in the evening 103 2°.—20th : Complainingof pain in the wound. In the morning, pulse 128, tempera-ture 100’6°; evening temperature 99 6°. The wound wasdressed; there was found some slight collection of pusbetween the stitches. Wound looking well; some stitchesremoved.-21st: A little pain, passing halfway down theforearm on the inner side ; can feel in little finger whenfirmly touched.-24th : Wound re-dre3sed antiseptically ;more pus between edges of wound ; the transverse one nothealed, and the one at right angles still open where the two

join ; one or two small sloughs came away; remainingstitches removed, and edges approximated by strapping.No elevation of temperature since the evening of the 20th.-26th : Less discharge; edges closer together ; re-dressed underspray. - 30th : Wound re-dressed ; small slough separatingat junction of the two incisions. Can feel when little fingeris gently stroked ; unable to abduct or adduct fingers.On April 3rd the wound was re-dressed, and lasted well.

On the 6th the antiseptics were left off, and zinc ointmentsubstituted. A week later there was more power in thelittle finger, and she felt well where before there was eitherpartial or complete loss of sensation.-On the 18th thewound was healed.On May 5th she left the hospital cured.On microscopical examination the bulbous enlargements

of the nerve proved to be true neuromata, there being littlefibrous tissue.

SUSSEX COUNTY HOSPITAL, BRIGHTON.VESICO-VAGINAL FISTULA ; COMPLETE CURE WITHOUT AN

OPERATION.

(Under the care of Mr. JOWERS.)C. P-, aged thirty-nine, was admitted on July 5tb,

1882, into Bristol ward. The patient complained of beingunable to "hold her water." Ten weeks before admission shewas confined. The last confinement was her sixth, and wasmore difficult than the previous ones. Labour lasted forty-eight hours, and forceps were used. On the ninth day afterthe operation her urine dribbled away for the first time.

I On admission there was a vesico-vaginal fistula at thevery top of the anterior wall of the vagina. The openingwas ragged, with cicatricial borders, and large enough toadmit the tip of a man’s forefinger. A female catheter waspassed into the bladder, through the fistula into the vagina.The anterior lip of the os uteri appeared to have beendestroyed, and the os uteri itself was left somewhat patent.

488

On July 7th a soft catheter was tied in, and the patientwas kept in the prone position.-21st: Owing to obstinatediarrhoea the catheter has been withdrawn.-24th : Thecatheter has again been tied into the bladder to-day.-28th : The catheter has slipped out during the night. Sheaffirms that much less urine runs away from the vagina, andalso that she has passed several ounces voluntarity at onesitting.—31st: Catheter again tied in.Aug. 4tb.-Catheter removed this morning. She says that

no urine runs away.—18th: As a small quantity of urineis again escaping the catheter is to be tied in once more.-20th : The patient is menstruating. The catheter has beenremoved. No urine is escaping.-25th : The patient wasinstructed never to empty her bladder herself. The urineis drawn off four times in the twenty-four hours. Shekeeps her bed. The sheets are never wet or stained.

Sept. Iht: She now gets up, and has complete controlover the bladder.-6th : The patient was discharged.Mr. Jowers remarked that he had never met with a

similar case. In the text-books there is no such resultrecorded.

CASE OF CYSTIC BRONCHOCELE CURED BY SETON.

(Under the care of Mr. JOWERS.)W, B-, aged twelve, was admitted on Oct. 6th, 1881,

into the Chichester ward. The patient had a swelling in theneck. He had had this for four years. It was situatedin the front of the neck on the left of the median line. It

occupied the position of the left lobe of the thyroid gland.It rose and fell during deglutition. It was about the sizeof an orange, and had the feeling of a cystic body ; it wasnot translucent. The right lobe of the thyroid gland wasnot enlarged. The swelling did not pulsate ; it was neitherpainful nor tender. Patient’s general health was quitegood.On Nov. lOth patient was put under chloroform. A small

trocar and cannula were thrust into the tumour ; two or threeteaspoonfuls of dark coloured fluid ran out. Tincture ofiodine and water, half and half, was injected. The trocarwas then thrust into another part, and about the samequantity of similar fluid ran out. This cyst was likewiseinjected.—11th: Patient has had no pain.-14th: Theiodine injections have had no apparent effect.

. Dec. 1st.—The swelling having regained its former size,the tapping has been repeated and undiluted tincture ofiodine injected.—3rd : The iodine has not caused anyinflammation.

Jan. lst.-The injection of iodine has been tried a thirdtime with no apparent effect.

Feb. 1st.—Four pieces of thick silk have been passedthrough the tumour by means of a post-mortem needle;there was no haemorrhage. ’

April 1st.—Since the last note there has been a markeddecrease in the size of the swelling. On some days there is nothing to be seen, and then again it will become obvious.Seton continued.May 12th.—As nothing abnormal has been observed of

late, the seton has been removed. June 21st.—The sinus left by the seton has long healed.

The swelling has not returned. Patient discharged.For the above notes we are indebted to Mr. B. Scott, i

house-sumeon.

NEWCASTLE INFIRMARY.EYELASHES IN THE ANTERIOR CHAMBER OF THE EYE,

THE RESULT OF A STAB.

(Under the care of Mr. WILLIAMSON.) PETER McD-, a schoolboy, eight years old, was ad- r

mitted on account of a lacerated wound of the foot, caused ‘

by the wheel of a coal-truck. His left eye was bandaged s

when he was admitted, and he explained that a fortnight i

previously his brother had stabbed him in the eye with a c

penknife during a quarrel. There was but slight inflamma- tion and very little increase of vascularity in the ciliary :

region. On the front of the cornea in the area of the pupil o

there was an irregular cicatrix about the eighth of an inch long, and inside the anterior chamber were what appeared tto be six or seven hairs lying vertically. The ends of someof them were engaged in the iris, without seeming to cause vany irritation. IFour days ter -admission the child was chloroformed. t

Mr. Williamson made an incision at the upper part of thecornea, and excised a piece of the iris. The hairs were thendrawn out with a pair of fine forceps ; one hair that escapedthe forceps was caught by a Tyrrell’s hook, All went on wellafter the operation, and the lad has now good sight with theinjured eye.Under the microscope the hairs were found to taper to a

point at one end, and to have a root at the other. Theywere about the length of the eyelashes. The lid was care.fully examined for a gap in the line of lashes, but none wasfound. Probably the knife was a blunt one, and caught thelashes about the middle, doubling them up and drawingthem out by the roots. They would then be carried on theend of the blade into the anterior chamber, remaining therewhen the knife was withdrawn.

It is remarkable that the hairs caused so little irritation,although some of them actually piejced the iris.

Rebiews and Notices of Books.On the Climate and Fevers of India. The Croonian Lectures

for 1882. By Sir JOSEPH FAYRER, K.C.S.I., F.R.S.London: J. and A. Churchill.

IN the present volume Sir Joseph Fayrer has supplied thedeficiency we regretted in his work on " Chronic Dysenteryand Tropical Disease," a deficiency which in our opiniondetracted considerably from its value as a complete treatiseon the subject which it discussed. We are the more in-terested in this matter since year by year the study oftropical disease becomes a greater necessity for every prac.titioner in this country as the means of intercommunicationbetween the various regions of our vast empire become moreextended and more rapid. Sir Joseph Fayrer is thereforeassured of an intelligent and interested audience to listen towhatever he has to tell them of diseases that are comingmore and more under observation in ths country. Thework opens with some valuable statistical details, chieflyrelating to the distribution of fever in different parts of

.

India, in connexion with the physical geography of thevarious districts, climate, rainfall, irrigation, babits, food,&c., and then passes to a consideration of the etiology of

tropical fevers generally. The origin and nature of malariaare discussed at length. This subtle foe, as far as England isconcerned, has long since, like scurvy, been banished toa pathological limbo, and not without reason, since inan open form it may be said almost to have ceased to

exist, except in a few-and it appears these are becomingless and less year by year-ill-drained and poorly-cultivateddistricts. Dr. Stephen Mackenzie’s statistics on this point,quoted by Sir Joseph Fayrer, are extremely interesting.From these it appears that in the London Hospital;which from its size and position is well qualified to affordinformation, in the year 1770, of 1483 in-patients therewere 21 cases of intermittent, with 1 death; in 1780,apparently an unhealthy year, there were among 1617 in-patients 59 cases of intermittent, but only 1 death; whilstin 1870, with 5218 in-patients, there were only 2 cases; andin 1880, with 6312 patients, there were 14 cases, but nodeaths. The question of malarial poisoning, however, has beenrevived of late, since many eminent authorities believe that,"though scotched, it is not killed," and that the diseasestill frequently manifests itself, though in an insidious andincompletely developed form. The chief interest, however,connected with the subject of malaria relates to the proba-bility of its having been caused by organisms. The subjecthas been investigated by Klebs, Tommasi Crudelli, andothers, who have all demonstrated the presence of organismsin the blood of ague patients and the soil of malarious dis’tricts. Dr. L. Aitken, of Rome, has in this country shownwhat he regarded as specimens of bacillus malaria, andDr. MacMunn, of Wolverhampton, discovered a bacillus inthe blood of a young African traveller during the cold stage