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of pain shooting up the right arm from the bitten finger;nothing amiss was noticed about the wound. The boy wentto bed at once, and passed a restless night. The nextmorning he was better; ate and drank well. On the 21sthe began to refrain from food; said he would take it 11 by-and-by." On the 22nd spasms were first noticed, when hedrank fluids. Since the night of the 20th he had not slept;had been very hateful; had had illusions, and frequent andcopious micturition. The spasms and restlessness increasedup to the day of admission, on the morning of which hefoamed at the mouth. He had no aversion to animals, andhe caressed the cat just before leaving for the hospital.On admission at the Casualty department the patient had

a most anxious and woful expression, gasping for breathlike a child after a fit of crying; at each inspiration theangles of the mouth were drawn downwards and the eyesopened. The face was pale and cold. There was an oldcicatrix at end of right little finger ; nail not quite renewed;no redness nor tenderness about it. Pain shooting up rightarm and down the right side. Bowels were said to haveacted freely after some jalap powder on the 20th.The patient was admitted into Edward small ward. At

3 P.M. was seen by Mr. Jones. Appeared in a state of greatnervous excitement, but at intervals could answer questionsrationally. On the least excitement, as of drawing bed-clothes up or down, or when spoken to quickly, the musclesof the face and neck were spasmodically affected, the chinthrown up, and angles of mouth drawn down. On tryingto swallow fluid (to which he had strong aversion) the spasmswere most intense; he gargled, and at last swallowed partof the liquid, while part was expelled by the mouth. Pulse88, quiet; temperature 1012°; skin warm ; feet comfort-

ably warm. No pustules nor enlarged glands seen beneaththe tongue. Five grains of calomel in glycerine, andthe sixth of a grain of the extract of belladonna everyfour hours. Hot bottles to feet. - 4 PM.: About thesame. Said he saw a big dog on the ceiling. Answeredrationally but refused fluids and ice. On bringing anice-bag in contact with the head intense spasms wereexcited. Pulse risen to 140.-At 10 :P.3i:. Mr. S. Jonessaw the patient, as he was much worse. He raved andwas greatly excited if looked at fixedly; spasm more orless at each inspiration; answered questions, but angrily;pugnacious, tried to bite and scratch bystanders. Bowelsacted freely after turpentine enema. Pupils fairly dilated ;perspiring. Temperature risen to 102°; pulse 130 to 140;respiration 24. Chloroform inhaled with most marked effect;instant relief. As soon as insensibility was produced, hebreathed tranquilly, the inspiratory spasm being entirelylost; slight tracheal rhonchus, as of mucus. Mr. S. Jonesthen determined to keep patient under the influence ofchloroform, and gave an enema of fifteen grains of bromideof potassium, with ten of chloral hydrate, every four hours.11 p.m.: Respirations at long intervals, and gasping. Heneither moved nor spoke. Previous laboured breathing be-came quiet. Pulse accelerated, and slightly stronger.Appearance tranquil. Temperature 101°; pulse 130.-11.45 P.M.: Chloroform given with Clover’s apparatus fortwo hours, but left off on account of accident with bag.Warm bricks retained in bed, and patient packed withblankets. Ice applied to nape of neck brought on spasmsand general disquietude. - Midnight: Nutrient enema,with half an ounce of brandy, fifteen grains of bromideof potassium and ten of chloral hydrate, given and re-tained. Chloroform kept up. Abdominal muscles rathertense. Thoracic breathing, with great uplifting of trachea.Feet and hands comfortably warm.

Sept. 25tb.—1 A.M.: Patient allowed to recover sensibilityfor a short time. He sighed very much, tossed his headfrom side to side, and threw his left arm about. Tempera-ture 10] 0.-1.30 A.M.: Chloroform still used. Patient ap-peared more exhausted. Breathing slower and less deep; 3extremities warm; pupils moderately contracted.-4 30A.M :Fully under chloroform. Tracheal rhonchus; skin hot anddry. Temperature ]02’80; pulse 160; respiration 42. Hadnot passed urine since admission. Bladder not distended;eyes congested.-4.45 A.M.: Enema of fifteen grains of bro-mide of potassium, ten of chloral, and half an ounce ofbrandy; eggs and beef-tea.—5 5 A.M. : Subcutaneous in-

jection of one-sixth of a grain of morphia. Chloroformadministered for about half an hour after the morphia in-jection, when the pupils were contracted to the size of a

pin’s head. He then seemed fully under the influence ofmorphia, and no chloroform was required till 6.30, whenhe came to, and the spasms at each inspiration recom.menced. Chloroform repeated. - 30 P.M.: Temperature102 60; pulse 120, very soft and feeble; respiration 26.Rhonchus all over the front of the chest. Face congested ;eyes half opened and turned upwards; skin dry and warm.Had not passed water nor motions. Bladder not distended;abdomen tympanitic; hands blue.-7.20 A.M.: Died. Beforedeath the tracheal rhonchus became more and more marked;lividity of hands and feet correspondingly increased. Duringthe last fifteen minutes of life the inspirations became irre-gular ; the inspiration prolonged, accompanied by muchrattling in the larynx. Artificial respiration kept up forten minutes. Pupils widely dilated. Thermometer intro.duced into the right axilla ten minutes before death, 1017°.Respiration ceased at 7.20, though the heart’s action con.tinued for some short time after.

Autopsy, fifty hours after death.-Body much decomposed.Results mostly negative. Brain congested. On section,the grey matter, both external and internal, was unusuallydistinct and congested. Numerous vessels in the whitesubstance. Internal organs congested; tongue congested.

ST. BARTHOLOMEW’S HOSPITAL.STRANGULATED UMBILICAL HERNIA IN A WOMAN

GANGRENOUS INTESTINE ; FÆCAL FISTULA MADE ;DEATH SIX DAYS AFTER OPERATION.

(Under the care of Mr. WILLETT.)FOR the notes of the following case we are indebted to-

Mr. James Shuter, M.A., LL.B., house-sargeon.E. E-, aged forty-four years. Had had an umbilical

hernia for ten or fifteen years, often strangulated, but alwaysreducible by taxis.

Oct. 24th, 1874.-At 11.30 A.M. the hernia became stran-gulated. At 5 P.M. Mr. Willett reduced a portion of thehernia by taxis, leaving what seemed to be thickenedomentum. Symptoms were at once relieved.25th.-12 noon: Hernia redescended during the night;

she complained of pain at the hernia, and of sickness.Tumour was larger than on the previous dsy. A dark-coloured patch was noticed at umbilicus.26th.-5 P.M.: Admitted to Casualty ward.-At 8 P.M.

gangrene of covering of hernia had gradually extended.When under chloroform, Mr. Willett made a free openinginto the sac, and found the contents of omentum and smallintestine strangulated by the fibres of the linea alba, andpart of it gangrenous and constricted, the result probablyof the first strangulation. The stricture being relieved, theintestine was laid freely open, and the edges stitched to thesides of the wound. Pulse 120 ; temperature 101°. Sub-cutaneous injection of a quarter of a grain of acetate ofmorphia at night.27th.-10 A.M.: Continuous retching; complexion dusky,

areo]Eo under eyes ; pupils rather contracted. Patient bad

slept well ; had taken four ounces of brandy in water, oneteacup of milk, and half an ounce of essence of beef. Iceand brandy kept down. Pulse 114; temperature 99°. In-

jection of a quarter of a grain of morphia. Tongue fairlyclean and moist.-2.30 r.M.: Comfortable, and under theinfluence of morphia ; tongue rather more furred ; retched,but did not vomit. Pulse 108.-8.30 r.M.: Intestine wasopened in a fresh place for escape of gas; essence of beefretained. Injection of a quarter of a grain of opium. Pulse108; temperature 100°.28th.-11.30 A.M.: Hands cool; patient very excited

and asks for brandy; is in no pain; passes her water;fseces and gas escape from false anus; tongue moist, whitefur. Had a pint and a half of milk with two ounces ofbrandy during the night; all vomited. In the morninghad half a pint of milk with five ounces of brandy, but allwas vomited. Pulse 100; temperature 98’40. Subcutaneousinjection of a quarter of a grain of acetate of morphia.-8.45 P.M.: Not sick since 11.30 A M. Had half a pint ofbeef essence, one ounce of brandy, and a pint of milk fordinner. Had four ounces of beef essence for tea. Pulse 108;temperature 982°.-11.45 r.M.: Tongue clean; no vomiting.Pulse 114; temperature 983°.

29th.-Morning : Slept fairly well; retched slightly, but

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did not vomit. Had half a pint of milk and one ounce ofbrandy. Pulse 100; temperature 984°.-3.30 P.M.: Pulse100; temperature 98-4°.—Evening: Slight pain in rightiliac fossa, which went away when she was moved; liquidfseces and gas escaped from false anus; vomited forcibly.Had a pint and a half of beef essence, two pints of milk,and three ounces and a half of brandy. Pulse 110 ; tempera.ture 996°. A quarter of a grain of acetate of morphia sub-cutaneously.30th.-Morning: No vomiting since last night; tongue

clean and moist. Pulse 114; temperature 1011°.-11.30A.M.: Had half a pint of essence of beef, half a pint of milk,and one ounce of brandy during the night; half a pint of milksince 8 A M. Pulse 118; temperature 101°. Had a quarterof a grain of acetate of morphia subcutaneously.-3 P.M.:Began to vomit. Charcoal poultice put to wound.-3.30 P.M.:A quarter of a grain of acetate of morphia subcutaneously.Midnight: Vomited some essence since 7 P.M.; pulse inter-mittent about four times per minute. Pulse 121; tempera-ture 1012°.31st.-Morning: Did not sleep all night; vomited every-

thing.-9 30 A.M.: Pulse 128; temperature 101°. Had athird of a grain of acetate of morphia.-1.30 P.M.: Sleptabout three hours; has taken nothing; vomited little;fseces pass from aperture. Pulse 144; temperature 100.5°.-11.45 A.M.: Tongue covered with brown fur and rather dry,especially at tip; has been spitting sharply with tight lipsabout three times per minute ; feels very weak, but has nopain. Had half a pint of milk with ice, and four ouncesof brandy, but vomited all, also three cups of tea. Pulsenot to be counted for rapidity; temperature 1007°. Acetateof morphia five-twelfths of a grain.Nov. 1st.-Died at 1 A M.Autopsy.-Abdominal parietes from above umbilicus to

the pubes, and for some distance laterally, were greatlyswollen, infiltrated, and congested; omentum and largeknuckles of small intestine projecting from the wound weregangrenous; there were offensive gases and much opaquefetid fluid in the peritoneal cavity. The brain was notexamined. The other organs were healthy.

ROYAL INFIRMARY, EDINBURGH.TWO CASES OF AMPUTATION THROUGH THE HIP-JOINT ;

RECOVERY.

(Under the care of Prof. SPENCE.)FoR the following notes we are indebted to Mr. J. Allar

Gray, M.A..CASE 1. Morbus c(M;6s; excision; amputation; recovery. -

Thomas H-, aged twenty, a clerk, was admitted intcWard 13 on Sept. 24th, 1874. The history records a seriesof abscesses near the hip-joint on two different occasions :once at the age of ten, when he had injured his hip by afall; and again five years ago, when convalescing fromrelapsing fever. Last May he had an attack of hsemoptysis.On admission he was seen to be a delicate, ansemic-

looking young man, emaciated to the last degree, andsuffering evidently from advanced morbus coxarius - a

diagnosis which examination confirmed. He was orderedwine and a ferruginous tonic ; the sinuses at the hip to bedressed with lotion of chlorinated soda, and extension appa-ratus to be applied. At first he seemed to improve rapidly,due no doubt to the altered regimen and rest; and afterresidence for five weeks in hospital he was so much betteras to be deemed fit for operation. The joint was accordinglyexcised on Oct. 29th. For a time he did well, but the dis-charge was always free, and often fetid; his health, how-ever, remained wonderfully good, notwithstanding the greatstrain. On Nov. l7th he had a slight attack of pleurisy,and on Dec. 20th examination with the probe showed a pieceof dead bone yet to separate. About this time he began tocomplain of pain in the region of the liver, which was seento be greatly enlarged, and was most probably affected withamyloid degeneration. For this, counter-irritation withtincture of iodine was applied every second day, and seemedto do some good. On Jan. 28th a small piece of bone whichwas pressing on the cicatrix of the excision wound wassnipped off. But during all this time the discharge wasvery free, and the patient seemed to lose ground. This

, state of matters continued, and on April 3rd half an inchof the upper end of the femur and some loose necrosed por-

j tions of bone were removed. After this the patient ap-l peared to be sinking fast, and, as a last resource, ampu-, tation at the hip-joint was had recourse to., April 13th.-Pulse 84; temperature 990; urine still with

a trace of albumen. To-day Prof. Spence amputated thelimb at the hip-joint. The patient having been placed un-der chloroform, Esmarch’s (flat) elastic bandage was applied

, tightly to the limb from the foot upwards, so as to extrudeI all blood from the part. An india-rubber band was next

brought round the thigh, immediately below the pelvis,drawn tight, and secured by being again passed round thelimb and tied. The flat roller was then removed. Mr.Annandale now compressed the femoral at the pelvic brim,while Prof. Spence transfixed the limb and cut the anteriorflap by the usual method. This he gave in charge to Dr.Duncan. The posterior flap was next cut, so as to have forone of its margins the incision made on the 29th Octoberlast for the removal of the head of the femur. The femoral

artery was immediately tied and the other arteries secured.A small projecting necrosed portion of the acetabulum wasthen removed with bone-pliers, and the surface of the flaps,especially where the remains of sinuses were observable,washed with a solution of chloride of zinc (twenty grains toan ounce of water). The flaps were then brought togetheralong the margins by silver-wire sutures, the extremitiesbeing left free for drainage. A pad of lint was laid alongeach edge of the wound, a fold of boracic lint over its sur-face, and the whole secured with a broad flannel bandagearound the pelvis.Though the patient lost little blood, yet towards the end

of the operation his pulse became very weak. On this indi-cation ether was substituted for chloroform as an anaesthetic,and an enema of brandy-and-water given, which had theeffect of strengthening the pulse. The enema was repeatedon the patient being put in bed, and champagne and brandy-and-water ordered in frequent small doses.14th.-Morning: pulse 110; temperature 100°. Evening: s

pulse 112; temperature 100°. Slept a little through thenight, and does not complain of much pain. Takes beef-teaand milk.15th.-Morning: pulse 118; temperature 101’6. Even-

ing : pulse 112; temperature 990. Urine of sp. gr. 1012,with a trace of albumen.19th.-Pulse has never been above 120, nor temperature

above 996°, since the 15th inst. The stump looks well; apart towards the inner aspect has healed by first intention,and the discharge is decreasing. Patient is looking andfeeling better than before the operation; sleeps well now,and takes his food. The urine still contains a trace ofalbumen.30th.-Patient improving in every way. Temperature

has been normal since the 19th instant, and continues so.Appetite good. The wound has healed with the exceptionof a small point in the centre of the incision, through whichsome discharge comes, and that part of the posterior flapwhich was formed of a previous incision. The latter, how-ever, is healing well by granulation. Urine yet contains atrace of albumen, and liver dulness remains much asbefore

May 27th.-Stump looking better, and patient muchstronger. Urine slightly albuminous. Sent to ConvalescentHouse.

Oct. 8th.-Patient’s health since his discharge has con-tinued good. Wound is now healed.CASE 2.-Chronic necrosis of femur; amputation through

hip-joint ; ; recovery.-Lilian S--, aged nine, was admittedto Ward 15, on 10th July, 1874, suffering from necrosis offemur and fibula. On admission, the leg was found flexedon the thigh from the contraction of the hamstring tendons,and the signs of extensive necrosis of the femur wereabundantly observable. Patient remained in the ward until20th January, 1875, when she was dismissed to the Con-valescent House. During this time several pieces of deadbone were removed-one a sequestrum three inches long-and the wounds were dressed with chlorinated soda or dilutecarbolic lotion, the patient meanwhile taking internallysmall doses of steel drops and dilute phosphoric acid. On17th February she returned from the Convalescent House,and had the hamstring muscles divided, so as to straightenthe limb. Dismissed again on 4th March, and admitted