the limb, there is no interference with the shaft of the femur, the length and normal direction. of which are still maintained. It is stated that no difficulty will be experienced in restoring the normal position of the limb if, at the same time, the adductors and the muscular and fibrous structures in front of the joint be divided subcutaneously. The relations of the surfaces of the divided bones to one another are very favorable to a restoration of the proper direction of the limb, whether this be fixed in a position of flexion, abduction, or adduction. The after-treatment in cases in which pelvitrochanteric osteotomy has been performed is extremely simple, as there is no necessity for long confinement of the patient, who, by the application of a plaster apparatus to the affected limb, and by elevation of the opposite foot on a patten, may be enabled to leave his bed on the fifth or sixth day. This operation, it is held, besides effectually removing the fixed osseous deformity will, provided the after-treatment be carefully attended to, in all probability, result in the formation of a movable joint, and in the restoration of the seriously impaired muscular action of the limb. These conclusions are based on the results of six cases in which pelvi-trochanteric osteotomy has been performed by the author, full reports of which are given in this lecture.-British Medical Journal.

Death Under Chloroform.

J. Hopkins Walters, M. R. C. S., Eng., surgeon to the Royal Berkshire Hospital, has recently reported the following two cases, one of death and the other of threatened death while under chloroform, in the London Lancet:

Case I. A boy aged six and a half years was anæsthetized by chloroform on March 27, 1896, for the removal of tuberculous cervical glands. In other respects he seemed to be healthy and had returned only a few weeks previously after being five months at the seaside. The operation was performed at 10:30 a. m., a breakfast-cupful of beef tea having been taken at 8 a. m. in lieu of breakfast. The glands were large and numerous; the surrounding tissues were infiltrated and unusually vascular, rendering the dissection down to the sheath of the vessels delicate, difficult and prolonged. There was free hemorrhage, amounting, probably, to three or four ounces (but this is always most difficult to estimate; it possibly might have been more; not much). The operation was almost finished when sudden arrest of oozing from the raw surface was noticed to take place, while at the same moment the experienced anæsthetist who was kindly giving the chloroform drew attention to the patient's pallor. I give in my friend's

own words the notes he has made on the case: "The boy had been under chloroform for about forty-seven minutes, during which time he took the anesthetic in a manner that gave rise to no more than ordinary anxiety. The first unfavorable sign noticed by me was a sudden and extreme pallor, not the bluish gray of respiratory failure, but a deathly whiteness. After a few seconds the breathing stopped. Immediately the radial artery was felt, but there was no pulse. The heart was auscultated, but there was no pulsation. Artificial respiration was at once performed, with the result that a very irregular sighing or gasping respiration was established. During the artificial respiration the air entered and left the lungs quite freely. The tongue was pulled out forcibly with tongue forceps and kept out while artificial respiration was maintained for three-quarters of an hour; nitrate of amyl was administered, and brandy and strychnia were hypodermically injected." In addition to the

above friction was made over the heart while the head was depressed and the body raised, but all to no purpose. The child was dead.

The case of threatened death under chloroform presents similar features to the above fatal case, but was followed by a happier result.

Case II. A child aged seventeen months, the subject of large double inguinal congenital hernia, was put under chloroform for the operation of radical cure. The child took the anæsthetic well and was fully under its influence when the incision was made. Two sweeps of the knife were followed by the application of a sponge, and on making the third sweep I noticed that blood ceased to flow. Looking round I found the child deathly white and apparently dead. Neither radial pulse nor heart pulsation could be felt. Artificial respiration was at once performed, the pulse returned, and in a few minutes the child had so well recovered as to enable me to complete the operation I had begun. In consequence of this contretemps I decided to postpone operating on the other hernia until after recovery from this operation. Owing to a little gastric disturbance the second operation was not performed for two months, and previously to the chloroform being given I warned the administrator, who had also been the chloroformist on the former occasion, to take especial care on account of the previous narrow escape. At the same stage of the operation apparent death recurred in a manner precisely similar to the previous occasion, with like treatment and fortunate result, followed, as before, by completion of the operation. This time we all were quite on the alert, and were thus able to make sure that it was a case of heart failure, the pulse stopping before respiration ceased.

These two cases present the following iden

tical features: (1) both were children within the age at which chloroform can be given with the greatest immunity from accident; (2) auscultation indicated a sound heart in each case; (3) on each occasion a Skinner's inhaler was used; (4) in neither instance was the operation commenced before the conjunctival reflex had disappeared; (5) in each the first indication to the operator was blanching of the wound coincidently with the observation by the anesthetist of sudden general pallor; and (6) uniformly the cause of death and threatened death was cardiac failure. The differences between the cases are that while the fatal case showed no unfavorable symptoms until the end of the operation the other exhibited them at the beginning; the one had taken a quantity of chloroform and the other. little; the one had suffered loss of blood and shock from the operation and the other none. These probably were the determining factors between death and recovery. On comparing with the "respiratory failure" dictum from Hyderabad the statistics of the Lancet commission appointed to investigate the subject of the administration of chloroform and other anæsthetics from a clinical standpoint,* one is struck by the enormous majority of reported primary pulse failures, which, together with the numerous cases of accidents occurring in the very earliest stage of chloroform administration, indicate that much has yet to be learned of the causes of these calamities. The observations of Rosenberg and Guérin seem to throw on them some light, and their conclusion that respiratory and cardiac depression are due to reflex rather than direct action deserves careful investigation. Certainly, until such conclusion is negatived or confirmed, the suggestion to avoid nasal inhalation or to neutralize the local effect of chloroform by thorough cocainization of the nasal cavity is worthy of universal adoption. That ether is so much safer than chloroform as to outweigh the great advantages of the latter has still, I think, to be proved after the honest tabulation of its delayed disastrous aftereffects.

Report of Two Fatal Cases of Hæmaturia.

Dr. Thomas H. Manley of New York reports the following interesting cases in the Indian Lancet for April 1, 1896:

It is well known in genito-urinary surgery that the sources of hæmaturia are exceeding numerous, and, that it is a symptom of a vast number of various pathological conditions along the urinary tract. It is seldom, howIt is seldom, however, that mortal exsanguination directly follows from it, inasmuch as we are usually able *Reading:

to control or moderate it, by appropriate meas

ures.

But, one case of it has come under my care in the male.

The patient was a vigorous young man, a carpenter by trade, who had fallen from a staging, about forty feet and fractured the body of the second lumbar vertebra. When he entered the hospital he was wholly paraplegic.

Shortly afterward, the house-surgeon noticed that there was a marked distension in the hypogastrium, and watery blood was trickling from the urethra. In the meantime the patient was deathly pale, with a thready flickering pulse, but, whether this was dependent on shock from the injury or the loss of blood was doubtful.

A catheter of larger caliber was now introduced into the bladder, when an enormous quantity of urine, thickly mixed with clotted and pure arterial blood issued through. In fact, fresh, warm blood continued to flow away after the urine was evacuated. Acided, acidulated drinks and stimulants were given, the bladder washed out with astringent solutions and ice applied over the loins.

The bladder soon filled again, and unconscious to the patient the discharge of blood recommenced from the penis. The housesurgeon now "rattled," tied a string around the root of the penis and sent for me. About an hour later, when I arrived, the patient was near the moribund state. The bladder had distended again, so that its summit reached the umbilicus. Over the region of the left kidney there was a tumor, fairly well defined, that produced a distinct bulging.

It was now evident that there was an extensive renal laceration of the cortex. It was evident too, that his only hope now lay in an immediate nephrectomy.

It was a serious question, though, if he now could survive this operation, which, in his sinking condition, might be impracticable, without serious consequences. After the various aspects of the case were submitted to him, he declined to undergo it. It was fortunate he did not, for he soon showed signs of approaching death and sank six hours later. His family peremptorily denied us the privilege of an autopsy.

This case, now on the records of Harlem Hospital, was entered on the 5th of November, 1892, in the surgical division, then in the immediate charge of Dr. Frank Hammond, the resident house-surgeon, and is recorded here, as a contribution to the literature of fatal traumatic hæmaturia, of a renal origin, dependent on spinal fracture.

The woman whose case will now be related, succumbed, from hæmaturia of pathological origin, in the bladder. She had cancer. In the vast majority of cases of cancer when the

growth does not start from, or impinge on some tubular structure, the integrity of which is essential to life, pain, loss of rest, etc., tends to cut off the afflicted part, but in the majority of cases, copious and oft-repeated hemorrhage does the fatal work of devitalization. In this case it did it with surprising swiftness.

On the morning of February 5, this year, Dr. James Moran of this city, called me in consultation to see a woman, whom he first saw early the evening previously.

She was of Scotch birth, medium size, rather spare build; she was 61 years old, a widow, who had given birth to seven children, at

term.

There was no history of malignant disease in her family, and she, herself, had always enjoyed fairly good health, up to the present time. For about two months before she had experienced more or less smarting in the bladder on urinating, and lately, had more or less straining and tenesmus, after voiding her urine.

Until the evening before, she was never aware of having passed blood in micturition. She had called the doctor because, in yielding to a desire to urinate she had passed but a few drops, when the flow ceased, and this was soon followed by the most acute vesical distress. The doctor on catherization evacuated more than a quart of urine, loaded with clots, and intermixed with bright colored blood. This brought immediate relief. Three hours later, at 11 o'clock, he was again hastily summoned to her for further aid; as she was again suffering from the same ensemble of symptoms.

This time the quantity of urine drained away was less, but it was so thickly intermixed with blood-clots, that it was with difficulty conducted through the catheter.

Chloroform Narcosis and Albuminuria.

V. Friedländer (Vierteljahrsschrift f. gerichtl. Med., Dritte Folge, Bd. viii, Supplement. Heft p. 94) investigated the urine of 100 male patients before and after chloroform narcosis, with reference to albumen and nucleo-albumen. Sixteen cases showed normal urine before and after anæsthetization, the narcosis. having lasted thirty minutes to two hours. Thirty-seven cases, in which the urine, before narcosis, was normal, showed afterward an albuminuria which almost invariably lasted only a short time. Forty-seven patients had a slight degree of albuminuria already before narcosis; in 22 no difference in the amount of albumen was noted afterward; in 9 cases the albuminuria was lightly increased; in I case a pathological urinary sediment was passed. In 7 cases the amount of albumen diminished or disappeared completely. This occurred also

in 6 cases in which there was a considerable amount of albumen in the urine before narcosis. The urinary sediment, which was found in 17 cases, consisted of casts and renal epithelium. The author considers that the alteration of the kidney is a tissue lesion which removes the power of inhibiting the loss of serum albumen, the causes of which lie in the poverty of oxygen in the blood, the destruction of blood corpuscles by the chloroform, the injury to the tissues by the liberated chlorine, and lastly, the lowering of blood pressure. As evidence for the occurrence of a tissue lesion, the author regards the fact that in 44 out of 56 cases investigated upon this point, after narcosis, the urine contained nucleo-albumen. -British Medical Journal.

Case of Sternal Dislocation of Second and Third Costal Cartilages and of Clavicle, with Fracture of Fourth and Fifth Cartilages.

Dr. Andrew J. McCosh of New York, surgeon to the Presbyterian hospital reports the following interesting case in a recent number of the Annals of Surgery: A man thirty-five years of age, was admitted to the Presbyterian hospital, February 21, 1895, who, in an attempt to jump onto the front platform of a slowly moving horse car, had slipped, and being caught between it and an iron pillar had been crushed and rolled between them, the space being six inches wide. The patient was a large man, his chest measure being forty-two inches. He fell to the ground and the car was thrown off its track. For a minute or so he was stunned, and then rose, entered another car, and managed with great difficulty and suffering to ride to the hospital, the distance of a mile. On admission it was evident that his distress was very great. He was suffering from severe dyspnoea and was markedly cyanotic. Every respiratory movement caused intense pain. He had frequent cough with bloody sputum. He could not lie down, but sat up in bed. Pulse 140; temperature 100° F.; respiration 48. Urine contained a trace of albumen and of sugar; specific gravity 1030. On examination there was subcutaneous emphysema of the neck and upper anterior part of the chest. On inspection it was seen that the clavicle and upper ribs were jammed backward. On passing the finger along the left border of the sternum it was found that the clavicle, second, third, fourth, fifth, and possibly the first ribs had lost their attachment to that bone and were dislocated backward and inward. The clavicle was displaced upward well above the top of the sternum and inward one and a half inches, where its sternal end pressed against the trachea. The second, third, fourth and fifth ribs were

displaced backward and inward, so that their sternal ends were situated opposite the middle of the sternum (inward displacement one inch), and about two inches behind that bone. The exact position of the first rib could not be ascertained. The depression for the second and third ribs on the left border of the sternum could be distinctly felt, and it was evident that the costal cartilages of these two ribs had been dislocated from the sternum, and apparently were still attached to the ribs. The sternal facets for the attachment of the fourth and fifth ribs could not be felt, but in their place attached to the sternum was felt a projecting piece of cartilage about half an inch in length. It was evident that these two costal cartilages had been fractured near their middle, and one-half remained attached to the sternum, while apparently the other half remained on the end of the rib.

The sternal end of the clavicle was raised without much difficulty onto the anterior surface of the sternum. This gave marked relief. It was necessary to hold it in this position during the further manipulations, as it was easily displaced. Attempts were then made to spring the ribs into position. The shoulders were pulled back and the spine hyperextended, both by steady pressure and by jerks. These attempts caused pain and were only partially successful. The inward. displacement could be reduced, but the backward could not be perfectly corrected, a displacement of half an inch still persisting in spite of the use of very great force. In order to keep the shoulders back, and thus reduce the deformity, various appliances and bandages were employed, but all they caused so much distress and so increased the cyanosis of the upper extremities that after repeated trials they were abandoned, and the patient was left sitting up in bed against a bed-rest with a pillow between his shoulders, and with the caution that he should keep them as far back as possible. He faithfully followed out the order, and he also found he was more comfortable in this position.

February 22. Distress and dyspnoea during the night had been great. Cough almost constant with bloody expectoration. Temperature 100° F.; pulse 130; respiration 24 to 36. Arms were tied behind, the pillow pressed into the hollow of his back.

February 23. Temperature 101° F.; pulse 124 to 140; respiration 46 to 56. Subcrepitant râles over left chest. Dyspnoea and cough

severe.

February 24. Temperature 100° to 102° F.; pulse 130 to 136. Delirious. Consolidation of entire left lung and effusion in pericardium.

February 25. Temperature 100° to 101° F.; pulse 120 to 130; respiration 34 to 44.

February 26. Dyspnoea less. Temperature 101° F.; pulse 124; respiration 32 to 40. Pericardial effusion diminished.

February 27. Temperature 100° F.; pulse 112; respiration 32 to 40. Less cough; more comfortable; lung clearing.

March 1. Steady improvement. Temperature 99° to 100° F.; pulse 110 to 120; respiration 30 to 36.

March 5. Temperature 99° F.; pulse 110; respiration 28. A broomstick handle was placed through his elbows behind his back. Cough almost disappeared. Dyspnoea slight; appetite good; free from pain. Clavicle retains its position on anterior surface of sternum, and ribs remain displaced backward for a distance of one inch.

His pulse, temperature and respiration soon sank to normal. He sat up night and day with the staff behind his back and through his elbows, which were bandaged to it. On March 8 he sat up in a chair. On March 23 he began to walk. On April 5 he was allowed to pass part of the day without the staff. The ribs and clavicle seemed firmly fastened in their new situation. There was no pain on manipulation of his chest. His general health was excellent. No cough. On April 6 he was discharged cured. On May I he was able to resume his work, and since that time has felt perfectly well. He suffers no pain, and would not know that he had been injured except when he attempts to lift a heavy weight, when he feels some weakness of the left side of chest.

Removal of the Entire Clavicle for Osteomyelitis; Complete Regeneration of the Bone.

At a recent meeting of the New York Medical Society, Dr. F. W. Murray presented a boy, fourteen years of age, with the following history: In May, 1895, he accidentally fell from a canal boat into the river, and was thoroughly chilled through. A few days afterward pain set in over the outer end of the left clavicle, febrile symptoms soon followed, and an acute osteomyelitis of the bone rapidly developed. In June he entered St. Vincent's Hospital, where the abscess was opened and the bone was scraped. In August he entered Dr. Murray's service at the New York Hospital. His general condition was fair, the local symptoms had abated, and three sinuses were to be seen leading down to the diseased bone. One was situated over the acromial end of the bone, another just above and a third just below the center of the bone, and each sinus was discharging a moderate amount of pus. With the probe it was ascertained that practically the entire bone had been denuded of its periosteum, and that it was a case of total necrosis. Under ether the entire bone was exposed through an incision extending from its acro