cough looser and pain much less severe; pulse | perature of last night was due to an error of diet. 106, temp. 100-5° F. No chills for 48 hours. 2 p.m.-Pulse 80, temp. 98 5° F. Allowed to lie 2 p.m.--A very fair day, but little pain, expector- on lounge a few hours. 8.30 p.m.-Pulse 88, ates quite freely a frothy mucus, tinged once or temp. 101° F. Can discover no extension of lung twice, with blood. It is probable, that some pneu- trouble. Feels very well, but strength gains very monia exists, in connection with the pleurisy, slowly; ordered stimulants to be used more freely. pulse 112, temp. 102° F. As a vaginal discharge 19th, 9 a.m.-Pulse 88, temp. 98-5° F. Presagain showed itself to day I ordered an injection of cribed Elix. Calisaya, Iron and Bismuth, (Wyeth). carbolized water. 5.30 p.m.-Pulse 110, temp. A teaspoonful three times a day. 101.8° F. 8.30 p.m.-Pulse 98, temp. 100.5° F. Temperature has not been as low for three days. 10.30 p.m.-Pulse 106, temp. 102-5° F.

12th, 9 a.m.—Slept fairly well, but had two or three hard coughing spells, pulse 108, temp. 102° F. Ordered Morph. Sulph. grs. ij. Spts. Chloroformi, 3ij. Vin. Xerici. ad 3j. M. Sig. 3i. p. r. n. 12 m. Pulse 108, temp. 102° F. Cough much easier. 6 p.m.-Pulse 104, temp. 101° F. 10 p.m. -Pulse 104, temp. 1022 F.

13th, 10 a.m.-Pulse 96, temp. 100° F. Babe was fretful and patient did not rest well, one or two hard spells of coughing this morning. Port wine substituted for brandy, only a small quantity taken. 12.30 p.m.-Temp. 100-5° F. Expectoration more free, still a trace of blood now and then. 9.30 p.m.-Pulse 100, temp. 101° F. Has coughed but little.

20th, 10 a.m.-Temp. 98.5° F. Cough improing very much and feels better in every way.

21st, 10 a.m.-Temp. 98.5° F. From this time the temperature never rose above the normal point, and improvement was constant, cough grew less and less, chest sounds cleared up and became normal.

July 6th-Went out for a drive, and on this day bowels first moved spontaneously. Toward the last of July, she went on a visit to relations in Toronto. At present writing (Sept. 13th) there is no cough, she has regained her flesh, and is, to all intents and purposes as well as ever.

REMARKS.-The points worthy of notice seem to me to be the following; and this paper has already reached such proportions, that I can only indicate them.

Ist. The success attained in stopping the hæ14th, 10 a.m.-A good night, with cough decid- morrhage, by separating the placenta as the os edly better; pulse 96, temp. 99-5° F. uteri dilated.

15th, 11 a.m.-Pulse 100, temp. 100-6° F. Has just been informed of the expected arrival of her mother from Toronto ; this has likely run the temperature up, symptoms otherwise improving. An enema was given this morning followed by a good motion. 2.30 p.m.-Pulse 96, temp. 98-5° F. 9 p.m.-Pulse 96, temp. 98-5° F. Has coughed scarcely any, and feels well.

16th, 10.30 a.m.-Pulse 96, temp. 100° F. 2.30 p.m.-Temp. 100° F. More cough to-day and feels tired. Examined chest, no friction sounds, no effusion; rough breathing over upper portion of right lung, and absence of sounds, with some dullness over lower lobe indicating consolidation. 8.30 p.m.-Pulse 92, temp. 100° F.

17th, 9 a.m.—Temp. 98-5° F. Slept fairly well, cough easier. 3 p.m.-Temp. 99° F. 9.30 p.m. -Cough troublesome, and temp. up again to 102° F. I fear some new complication.

18th, 9 a.m.-Slept well, with but little cough; pulse 90, temp. 98.5° F. Perhaps the high tem

2nd. The, almost fatal, accident from chloroform, during an accouchement.

3rd. The sudden rise of temperature on the 4th and 5th days, followed by an absolutely normal temperature until the 9th day. I cannot doubt that the first rise of temperature was due to blood poisoning, and it would seem as if the second must have been produced by a fresh dose. I attributed it, whether correctly or not, to an escape of septic fluid through the right Fallopian tube, upon the patient first assuming the erect position.

4th. The effect of the aconite. A reference to the text will show that its administration was always followed by reduction of the pulse rate, and in most instances this was accompanied by a corresponding fall of temperature. In suitable cases, I am inclined to think it a valuable drug.

5th. The fact that the constitutional symptoms were not as severe as the high temperature would

indicate.

6th. The occurence of pleurisy on the seventeenth day. As there was no exposure, this was looked upon as a result of the septic poisoning.

instead of the knee in the bend of the elbow and Gross states that he has met with many cases with that for a fulcrum attempting flexion and where all efforts to reduce proved unavailing after extension by the surgeon himself; and by using the third week, and sometimes after the second; pulleys with a band around the chest if the patient and he further states that three weeks' duration is very strong and muscular; or finally, by adopting always renders the reduction of this dislocation the method practised in this case with success, and very difficult, although he has met with some cases which I shall here detail: The patient was placed that have been reduced after two months' standing. upon the operating table and brought fully under Sir Astley Cooper is said to have succeeded in the influence of chloroform. He was then placed reducing this dislocation after three months; Mal-near the edge of the table, and turned partially gaigne at three and a-half; Blackman, Brainard upon his side, so that the arm hung free beyond and Westmoreland after five months' standing, and the edge of the table. The middle and upper part Gerdy and Drake even at six. But such cases as of the humerus and the patient's body were grasped these are extremely rare, and the danger of injuries and firmly held by two strong assistants, while the to the parts, followed by violent inflammation, hand and lower part of the forearm were seized suppuration, and gangrene, is too great to justify a upon and held by two other assistants. Equable and persistent traction was made, and pressure

exercised upon the upper part of the forearm in such a manner as would tend to lift it away from the trochlear surface of the humerus, at the same time that extension was being made. I also made pressure downwards and forwards upon the projecting olecranon process with one hand, while with the other I grasped the forearm near the elbow to assist in pulling the ulna from the humerus, and also to direct, at the proper time, the necessary flexion of the arm. After a few minutes of steady effort in the manner here stated, I distinctly felt the joint begin to yield and the bones to separate, the act being accompanied by a sensation as of something tearing. I then directed the assistants who held the forearm and hand to slowly and cautiously flex the limb, without relaxing their hold or lessening the traction they were making I also continued to bear downwards and forwards upon the olecranon and the upper part of the forearm close to the joint. As flexion was gradually produced, I had the pleasing satisfaction of feeling the olecranon glide forwards, and the trochlea of the humerus assume its wonted position in the vacant sigmoid cavity. The limb was then flexed until the fingers of that hand were placed upon the top of the opposite shoulder; and after extending and flexing it several times to make sure that any new adhesion would be broken up, and that the bones were in proper position, the arm was flexed at a right angle, put up in an adjustable elbow splint well padded, and suspended high up across the breast in a sling.

For the first twenty-four hours there was severe pain, which required to be relieved by morphia; there was also considerable swelling and redness, to control which we kept a lotion of acetate of lead and laudanum constantly applied. All the urgent symptoms, however, gradually abated and in a few days the patient was able to walk about the wards of the hospital, apparently free from suffering, and greatly pleased at the new position in which he found his arm. At the end of eight days we began to make passive motion of the joint, which yielded without difficulty, though, of course, not without some pain.

On the 1st of February, thinking himself well enough, and being able to move the joint to some extent voluntarily, he left the hospital, since which time I have heard nothing from him.

do not expect to instruct my brethren in the profession in the diagnosis and treatment of dislocations of the elbow-joint, nor have I entered minutely into details; for I feel that, to assume the position of an authority before so large and learned a body as this is, would be to tread upon dangerous ground, and to reiterate facts with which you are all perfectly well acquainted. Nevertheless, there are some thoughts suggested by the subject which it may not be amiss to discuss, and which might be profitably pondered over by some of the younger members of our profession.

First, then, as regards diagnosis.—The diagnosis of injuries of the elbow-joint are admittedly difficult. The complicated nature of the joint, the number of epiphyses about it which may be separated from their bones, especially in childhood, and the swelling which generally so quickly supervenes, all conspire to obscure the real nature of the injury, and to leave the inexperienced surgeon in doubt as to the character of the lesion before him, and hence unable to pursue the proper line of treatment.

There is no class of cases in which an accurate knowledge of anatomy is so requisite as in dislocations, and none which puts the real knowledge and skill of the surgeon to so crucial a test; and it is a thorough acquaintance with the anatomy of the joints-bones, ligaments, and muscles surrounding them-which alone can qualify the practitioner to become successful in this department of surgery. Several times has it been my lot to see dislocation of the head of the humerus into the axilla, treated as a sprain or bruise by an M.D. until the time for any hope of reduction had past; and the case here reported is the third one of the kind that has come under my care in which treatment by another surgeon had been unavailing; and doubtless many of you, gentlemen, have had similar experiences. This man had been for the five weeks previous to his coming to the hospital, that is, from the receipt of his injury, under the care of another medical man, who not only honestly stated that he could not remedy the deformity of the man's arm, but that he could not satisfactorily decide upon the real nature of the injury. Another case occurs to my mind at the present, which will serve to illustrate the ease with which a mistake may be made, and the effect which such may have upon the

In calling attention to the report of this case, I reputation of the surgeon.

About eight years ago a little girl æt. 10, but is justly chargeable with the consequences of failwho is now a young lady with as fine a pair of arms ure; and the records of the law unhappily teem as one could wish to see, was brought to my sur-with examples of a compulsory retribution as the gery for the purpose of having me examine her award of ignorance or neglect. But in the case elbow, which had been hurt three weeks previously. now under consideration which sets at naught the On examination I found the characteristic symp-knowledge and the foresight of the most experitoms of backward dislocation of radius and ulna-enced, a surgeon can only render himself responsipartially flexed arm, hand between pronation and ble for the result by the assumption of power which supination but inclining to the latter, prominence he does not possess, or by volunteering an unguardof the trochlea in front and shortening of the fore-ed pledge of his ability to restore the joint to its arm, projection of the olecranon process backwards, former condition of health. This is obviated by a and increase of the distance between the internal candid avowal of the difficulties of the case, and condyle of the humerus and the tip of the olecra- his willingness to avail himself of the co-operation non. The arm was still considerably swelled, but of others, who can at least lighten his burden by yet all the necessary diagnostic points could be sharing his responsibility." made out. I explained the nature of the case to Secondly, in looking at the legal aspect of joint her parents, and with their consent and assistance injuries, we should never forget that the elbowchloroformed the child, and reduced the disloca-joint offers one of those intricate problems which tion without the least difficulty. The arm was are too often presented to the surgeon for solution. properly bandaged and in a few weeks all traces of In the case of Hoban v. Parker, tried twice at the injury had disappeared. Now the medical the Kingston assizes (the last time in September, man who had charge of the case before I saw it, 1881), the patient in some kind of a row received had pronounced it a sprain and had been treating a severe kick upon the elbow-joint. The case was it with fomentations, liniments, etc., to the damage diagnosed by the attending surgeon to be a fracof the child and the great vexation of her parents.ture, and treated as such; for some reason, howI explained to them the difficulty frequently experienced in ascertaining the exact nature and seat of injuries about joints; but although they listened to me with attention, and no doubt believed me, yet this could not take away their feeling of dis-set up by the plaintiff was ignorance on the part of trust, yea, almost enmity, towards the other medical man; for they thought that if I could detect the true nature of the injury and remedy it so quickly, the gentleman they had been employing could not be up to the mark as a skilful and reliable surgeon. The consequence was, that he lost not only the practice of that family, but of all the families in the neighborhood which they could influence.

ever, gangrene ensued, and the result was that the arm had to be amputated above the elbow. Upon examination of the joint after amputation, the bones entering into it were found to be entire. The plea

the surgeon in not detecting the true nature of the injury, and improper treatment by bandaging the limb too tightly. After two trials at court, which must have been a source of great expense and vexation to the surgeon, the jury disagreed as to a verdict, and the case was dismissed; but another emphatic lesson was taught thereby, of the necessity of knowledge and care in elbow-joint injuries, and of the propriety of calling in another surgeon, at least, to share the responsibility in all doubtful cases.

But knowing the difficulties which beset this and some other injuries and dislocations, we should protect each other as far as possible; and any one of us when in doubt should not hesitate to seek the We may here again quote the impressive words opinion of some competent professional brother. of Skey: "The penalties of the law are justly enTo set this matter before you in a most elegant forced on those who play a single-handed game, by and emphatic manner, permit me to quote from which they deprive their patients of the advantages Skey: "A surgeon is justly responsible to society to be derived from the experience of others; wherefor the entire restoration of many forms of injury as they should rely on the well-known adage, which to their condition of health, provided no extreme under no circumstances is more pertinent than when or unusual difficulty exists in the nature of the applied to a medical man placed in this critical poaccident, or arises in the course of treatment, and | sition, that 'union is strength.'"

Thirdly, we may notice the causes that render this dislocation so difficult of reduction after a few weeks' standing.

Dr. Samuel D. Gross, in the fifth edition of his masterly work on surgery, states that he was not prepared to assign any reason why a luxation that is so easily rectified if properly managed in its earlier stages should so soon become utterly irreducible, resisting and defying all the best directed efforts of the surgeon when allowed to remain for a few

weeks.

It seems to me, however, that if we carefully consider the construction of the elbow-joint, and duly appreciate all the displacements that occur in backward dislocation of both bones of the forearm, we cannot be at a loss to assign a good and sufficient reason for the quickness with which this luxation becomes irreducible. Of the four ligaments surrounding the joint, the anterior would in all probability be torn loose from the coronoid process of the ulna; the posterior being loose might escape injury, but on account of its thinness some of its fibres might be broken through; the internal lateral ligament would have its posterior portion which is attached to the inner magin of the olecranon torn through, and the external lateral ligament would suffer laceration in some of its anterior fibres. As regards the muscles, the supinator brevis would have some of its upper fibres torn through, and the remainder put upon the stretch, to be accommodated by supination of the hand. The anconeus would be relaxed, but from its shortness and the projection of the ulna backwards, might be more or less lacerated; the powerful triceps muscle would be relaxed from the approximation of its points of attachment. All the remaining muscles of the forearm, both anterior and posterior, that arise from the internal and external condyles of the humerus, would be relaxed by the projection of the lower end of the humerus forwards towards their points of insertion. The biceps muscle would be put upon the stretch, but this would be partially compensated by the supination of the hand; and the brachialis anticus alone would be the only muscle that would suffer severe stretching and have a tendency to restore the trochlea of the humerus to the sigmoid notch.

Now if we consider that, in three or four weeks, new adhesions will form smongst the lacerated fibres of the ligaments, and of the muscles, and

that all the strong muscles of the forearm and
the powerful triceps will have become contracted,
shortened and accommodated to their new con-
dition, we can readily perceive that the bones
will be held in their new position as firmly as
Thus,
they were previously in their natural one.
the force required to lift the trochlea of the humer-
us backwards over the coronoid process of the ulna
must be sufficient to break up all new adhesions,
and to stretch the triceps and all the muscles of
the forearm to the same length they were when
the luxation occurred. This we know is no easy
task, for a muscle requires a great force to stretch
it suddenly; and hence the force required to re-
duce a dislocation of the elbow backwards must be
fully equal to that which produced it.

The anatomical and physiological aspect of this dislocation fully accounts, I think, for the difficulty experienced in reducing it after a few months standing, and afford us a clue to the means requir ed for its successful treatment.

Now if we regard injuries of the elbow-joint in any of their phases-whether as to the difficulties attending them-the consequences of improper diagnosis and treatment of the patient-the inevitable results to the surgeon's character and reputation-the legal vexations and expenses that may follow-and the nice anatomical and physiological details which they iuvolve, we must, I think, agree that they form a class of cases that are well worth our careful and intelligent study.

THE CAUSES AND CONSEQUENCES OF
DEFECTIVE VISION DURING SCHOOL
LIFE.*

BY L. L. PALMER, M.D., TORONTO.

It was not my intention to take up the time of this Association this year with a paper, until about a week ago, our worthy President suggested to me that I write up the subject of hygiene of schools, which in its importance so commended itself to my judgment, that I have undertaken to consider at least one phase of the question which may form a nucleus for further thought—a phase by no means the least important of all the conditions that affect early life-viz., The Causes and Consequences of Defective Vision during School Life.

* Read before the Ontario Medical Association, June, 1882.