cried out; movements at the wrist and elbow were, however, painless. No change occurred for a week, except that the pain, on movement at the shoulder-joint, grew rather less. At the end of that time the mother began to notice an enlargement in the upper third of the arm, which, at first hardly perceptible, increased day by day in size until the infant was brought to me for treatment. The origin | of the trouble was attributed by the mother to a fall sustained a few weeks previously, at which time it was supposed that fracture of the arm or a dislocation at the shoulder-joint had taken place.

When she first came under observation (February 19, 1879), the following brief notes of her condition were recorded:

She was at that time three months old, and, although decidedly ill nourished and thin, especially about the buttocks and lower limbs, was not actually emaciated. She had been fed upon condensed milk, which seemed to be well digested, as she suffered neither with vomiting nor diarrhoea. There was a rather scanty erythemato-papular eruption about the buttocks, tending to moisture. The epidermis was peeling off in fine flakes here and there. The child was suffering with well marked nasal catarrh, together with slight bronchitis. Circumstances prevented a careful examination of the bone lesions at the time, but the following appearances were noted. There was a pigeon-egg-sized enlargement on the anterior and inner face of the left humerus, in its upper third, which appeared slightly, or not at all, painful to the touch. The arm hung in pronation quite flaccid and powerless, excepting that the muscles of the fingers seemed to retain some strength. She was ordered ung. hydrargyri, spread upon a flannel belly-band.

Two weeks later she was seen again, and her general condition noted as worse. Although her appetite continued good, she had become more emaciated, and suffered with nocturnal pains. The mucous patches about the buttocks had healed entirely, but the bone lesions had become more marked. About a week after the first visit the mother had noticed a sudden loss of power in the child's right arm, unaccompanied, as she thought, by swelling at any point. On examination, I found her condition as follows. The right humerus displayed an enlargement at the lower third, which was flattened before and behind but bulged out on each side. The tumor was somewhat tender on pressure. Even slight movements of the arm at the shoulder caused pain there, although there was no swelling about that joint. At the junction of the lower and middle thirds of the left humerus there was a somewhat larger tumor, which appeared to proceed from the anterior and outer surface. Both wrists were somewhat swollen, the left more markedly so than the right; the lower epiphyses of both bones seemed to be in

volved. There was some some slight motion, apparently, between the epiphysis and the diaphysis of both radius and ulna. In the lower third of the left femur there was a swelling just above the epiphysis; the kneejoint was in no way involved.

On March 13 the first opportunity offered for a thorough examination, when the following appearances were noted. The bones of the skull were apparently quite normal and free from enlargements, as were also the vertebræ, scapulæ, clavicles, ribs, and pelvis. There was some enlargement about the head of the right humerus, where a collar-like ring of bony deposit could be felt. The swelling on the outer side of the shaft of the humerus noted at the last examination had diminished somewhat in size. There was a very slight enlargement of the lower end of the right radius, but otherwise the bones of the forearm and hand were free from apparent disease. The radius and ulna were freely movable upon each other at the wrist. The pseudoparalytic condition had nearly disappeared. A similar condition existed in the left arm, excepting that the humerus was distorted, being bent at its upper third, at the point of enlargement above noted, to an angle of nearly forty-five degrees, and bow-shaped, with the convexity outwards. There was still some tenderness about the shoulder-joint, although not as much as there had been a week previously. There appeared to be a partial separation between the diaphysis and the upper epiphysis of the left humerus. The condition of pseudo-paralysis in the left arm was beginning to improve, Nothing abnormal could be noticed in the lower limbs, excepting some slight enlargement in the lower ends of the tibiæ. Motion in the left leg seemed to be quite restored; in both it was now normal. There appeared to be slight cutaneous anææsthesia. The liver was found, on percussion, to be somewhat enlarged, the spleen decidedly so. The child's general condition was improving.

A curious phenomenon exhibited itself for the first time during this visit, namely, a peculiar recurrent spasm of the larynx. This spasm occurred in frequent attacks of brief duration, coming on quite suddenly, without cough or other premonitory symptoms, checking the breathing entirely, and giving rise to the most agonizing efforts at inspiration, lasting for some seconds, and finally giving way, with a long-drawn breath, not followed by a cough. It appeared to be excited by handling, particularly by laying the infant on its back, and, by the mother's statement, had occurred for some days past during the daytime but not at night. The left arm was confined in splints, with a view of preventing further deformity and restoring it to its normal shape. The medicated bandage was continued.

On March 14 the general condition was the

same. It was observed that the laryngeal spasm seemed to be accompanied with a slight cough. The bandage was discontinued and the following mixture ordered:

R Hydrarg. bichlor. corros., gr. 4;
Potass. iodid., 3j;

Syrupi et aquæ, àà 3ss.

M. Six drops to be taken thrice daily. On March 21 slight salivation was noticed, and the medicine was reduced to fivedrop doses. The child was becoming emaciated. She did not seem to suffer so much

pain, however, and the condition of the bones was evidently improved. The head of the humerus, it appeared, had been decidedly enlarged, since it was now evidently much reduced in size, while the swelling on the shaft of the bone had also become smaller. The enlargement on the right humerus had

also become lessened in its dimensions. There were no other swellings, excepting in the bones of the carpi of both hands, which appeared slightly thickened. The radius and ulna on both sides were normal to all appear ance. The lower ends of the femora of both sides seemed slightly enlarged, and also the heads of the tibiæ, although these changes were uncertain. The phalanges of the great toe of the right foot were slightly swollen, particularly the second. There were no other bony lesions in body or limbs. The submaxillary and sublingual glands were considerably enlarged; slight pressure upon them gave rise to evident pain and called forth the laryngeal spasm above noted, which also continued to arise spontaneously at intervals, though not so severe as it had been. It should be here stated that neither up to this time nor subsequently were any lesions of the interior of the mouth or pharynx observed, nor did there appear to be abnormal tenderness on pressure applied outside of the larynx and glottis. The infant continued to eat well, being fed on condensed milk. She was di

rected to continue the medicine, together with Keasbey & Mattison's infant food. The arm was kept in splints; it was gradually regaining its proper shape.

On March 26 it was noted that the laryngeal spasm was less marked. The left humerus was smaller, but was still very much bent out of shape. In other respects the bony troubles were in very much the same condition as at the last examination. The medicine, not agreeing very well, had not been given with regularity. It was stopped and the bandage was again directed to be used. This was the last time at which

now

the child was seen. She was taken out of town shortly after, and I have been unable to learn her subsequent history.

It will be observed that the syphilitic history of this infant, both as regards its parents and with reference to the characteristic lesions displayed almost from the

moment of birth, is complete and beyond question. In addition, the influence of treatment, although this was imperfectly carried out, was decidedly favorable. There can be no doubt as to the diagnosis of these lesions; no question of rickets, since the whole history of the case forbids such a supposition.

The chief symptoms noticed, in addition to the skin manifestations, the nasobronchial catarrh, the laryngeal spasm, and the cutaneous anesthesia, were those connected with the osseous system. To recapitulate these: there were enlargements about the head of both humeri and in the upper third of the left humerus, at the junction of the middle and lower thirds of the same bone. There was evident separation between the diaphysis and proximal epiphysis in the left humerus, together with motion at this point and marked resultant distortion of the limb. There was an enlargement in the shaft of the right. humerus in its lower third, and there was of both radii and ulnæ, the shafts of which some slight enlargement at the lower end were movable on the epiphyses. The bones of the carpi of both hands were enlarged. In the lower limbs the distal ends of the femora were slightly increased in size, as were also the heads of the tibiæ. The phalanges of the right foot were also the seats of similar changes.

In connection with these osseous changes the peculiarly striking pseudo-paralysis of both arms and of the left leg is particularly worthy of notice. As will be seen by reference to the notes, it was this condition of affairs which first excited the mother's anxiety and caused her to seek advice, for the bone lesions had not at the time of her earliest visit attracted much attention. It was this condition of pseudo-paralysis which first drew the attention of Parrot* to the disease, causing him to give somewhat undue prominence to this symptom, which Taylor rightly considers as only of secondary importance.

"This false paralysis," says Taylor,† "is simply an indisposition or want of power to move the limbs, owing to a false point of motion existing in their continuity. The same features are observed, and the same conditions obtained, in cases of fracture

Sur une pseudo-paralysie causée par une altération du système osseux chez les nouveaux-nés atteints de syphilis héréditaire. (Archives de Phys. Norm. et Path., 4me an., Nos. 3, 4 et 5, 1872.)

Loc. cit., p. 110.

of bones, and, as they are explained in so simple a manner, I hardly think it necessary to so magnify their importance as to burden literature with another name for them. The appearances presented by children whose bones are thus affected vary, of course, with the particular one involved, as with the end which is involved, and are in the main those which would be observed

if any of them were fractured, except, perhaps, that there is much less sensitiveness and swelling of the surrounding parts generally. . . . Owing to the existence of a false joint, or rather false point of motion, there is a total relaxation of the muscles, and no movements are made in the limb.'

As to the bending of the humerus, this lesion, although only rarely observed, has been noted in other cases. The condition was due, as can easily be understood, to the preponderance of action of the flexor muscles over the extensors acting upon the lower segment of the limb in which a false joint existed.

The pathology of the bone lesion may be briefly stated as periostitis, osteitis, and, perhaps, as Taylor says, osteochondritis. Of course it is not simply inflammatory; we have also a deposit of granulation tissue. With regard to the laryngeal spasm, so prominent a symptom in the latter part of the history of my case, I have recorded it as of interest, but am unable to give any explanation as to its cause, though believing it to be connected with the syphilitic affection.

A CASE OF INTRACAPSULAR FRACTURE OF FEMUR, WITH TREATMENT AND RESULT.

BY S. R. SKILLERN, M.D.

N the 21st of August, 1878, while crossing the yard of one of the hotels at Saratoga (at night), Governor R., aged 65 years, fell, the left hip striking upon a conical stone imbedded in the earth with sufficient force to dislodge it.

After the patient was got to bed, the pain was lessened and sleep induced by repeated doses of morphia; and the following day, with the assistance of Dr. Saulsbury, of Delaware, the governor was etherized, and the intracapsular injury diagnosed. On pulling the leg well down and rotating the thigh, crepitus above the trochanter, and apparently within the capsule, was distinctly heard and felt.

In consultation it was decided to convey the governor at once to Philadelphia, a procedure fraught with not a few difficulties, in

consequence of his weight and the numerous changes necessary in his transportation. Arranging the patient upon a cot, and providing a number of pillows, he was etherized and conveyed to the train, and was kept more or less under the influence of ether until we arrived at Philadelphia.

The day following our arrival, and two days after the date of the injury, treatment was begun by etherizing the patient and Satisfied with the correctness of our original making a further examination of the parts. diagnosis, the next question was as to the proper position and apparatus to be employed, Convinced that the age and temperament of my patient would militate against his recovery should he be subjected to the confinement necessary with splints of any kind, I resolved on employing a chair in lieu of bed and splints. The chair selected was what is usually styled an invalid-chair,—the back, seat, and foot-rest made so as to be secured at any angle desired.

Placing the patient comfortably in this chair, and adjusting the fractured surfaces of bone, I found that in order to keep the surfaces in apposition it would be necessary to I devised a concave metallic pad, or plate, adopt other means than position. To this end three by four inches in size, covered with soft leather, provided with slits to hold in position a stout elastic band. The pad was applied over the trochanter, and the band around it and the pelvis drawn moderately tight and buckled. This served so well in keeping the fractured surfaces in apposition that nothing else than comfortable support for the leg was needed, the patient being able to change from a recumbent to a sitting position at will.

In this way the governor submitted cheerfully to treatment, and was at the end of six months able to walk quite as well as he ever did. He has but slight shortening, certainly not more than half an inch, and says that he feels but little discomfort after walking continuously for an hour or more.

With the hope of getting the rare result, bony union, in this case, in addition to keeping the fractured surfaces in close apposition,— which the pad and band served well to do,I gave the patient full doses of the hypophosphite of calcium four times a day : how far that assisted in the result may be matter of opinion.

BENZOATE OF SODIUM AS AN ANTIPYRETIC AND ANTISEPTIC.-It can be taken in doses of two to four drachms daily without unpleasant effect, and is reported, on good authority, to have proved highly beneficial in diphtheria, acute rheumatism, erysipelas, and puerperal fever. The testimony regarding its value is sufficient to make it worth a trial. It does not reduce fever so quickly as quinine, but the effect is longer continued.-Medical Times and Gazette, vol. i., 1879, p. 597.

antisyphilitic remedies we will subject it to the therapeutic test.

The patient has taken iodide of potassium in ten-grain doses three times a day during the past fortnight. We will continue the use of this drug, but in increasing doses until we reach thirty grains three times daily.

The characteristic lesion of locomotor ataxia is sclerosis (gray degeneration) of the white posterior columns of the cord, extending to the posterior roots of the spinal nerves. If the ataxia be directly due to syphilis, as the clinical history of the case before you seems to indicate, the nature of the histological changes in the cord is unknown.

It is possible, in view of the frequency of both diseases, that syphilis and sclerosis of the posterior columns may have in our patient an accidental and not a causative association.

TRANSLATIONS.

A CASE OF SUPPOSED TUBERCULAR MENINGITIS CURED.-Dr. Foucart (La France Méd., 1879, No. 59) saw a little boy, 51⁄2 years of age, who for six weeks previously had shown a remarkable change of character; he had become capricious, headstrong, and ill-tempered; when crossed, he lay on the ground and refused to rise, or he crouched in a corner without speaking. When seen on February 13 the child had become even more sulky; he would not eat or play; he had been constipated for two days. A purgative improved his general condition decidedly, but only for a time; he became constipated again and sleepless. On examination on February 17 the patient was found lying on his side in bed, pale, with a spiteful expression; the eyes habitually closed; the pupils dilated irregularly and contracting very slightly on the admission of light. He spoke little and hesitatingly; his pulse was 120 to 136, temperature 100.4° F. The child frequently carried his hands to his head, but did not complain of headache; he moaned occasionally; tâche méningitique; respiration quiet; lungs sound; constipation, but no vomiting; incontinence of urine. Diagnosis meningitis, probably tubercular. Ordered calomel and jalap, sinapisms to the calves, potassium bromide (gr. xxiv) at night.

Later, leeches were applied. The next day the bromide was increased to fortyfive grains, with eight grains potassium iodide. The shaven scalp was painted with tincture of iodine. Within the next following days hydrocephalic cries, grinding of the teeth, etc., were observed. Notwithstanding all these symptoms, amelioration began to take place in a few days, and by the end of two months he appeared to be entirely cured. The bromide was continued for three months.

CAUSE OF THE PAIN IN PAINFUL SUBCUTANEOUS ANGIOMA. —At a meeting of the Société de Chirurgie (La France Med., No. 60, 1879), M. Trélat gave some account of a woman of 52, who came under his care with a tumor of the posterior region of the elbow, of two years' duration, following a fall. The diagnosis was made of painful subcutaneous angioma. The tumor looked like a lipoma, with a distinctly circumscribed bluish discoloration of the skin; it was very painful. operation for the removal of the tumor was followed by perfect relief. The cause of the pain was found to be in the presence of a number of nervous filaments in the tumor. M. Trélat remarks that pain is not characteristic of any particular variety of tumor; even lipomata are occasionally painful.

An

GENERALIZED XANTHELASMA WITH ICTERUS AND HYPERTROPHY OF THE LIVER. - M. Ernest Chambard communicated the following case to the Société Clinique (La France Med., 1879, No. 60; see also Nos. 1 and 2). The patient, who had suffered with jaundice, and whose case had previously been reported, died. The postmortem examination showed patches of disease not only about the eyelids, but also in the larynx, trachea, and bronchi. The other organs showed no signs of this disease, but there were hydatid cysts in various localities, and particularly in the liver, which was much enlarged. [The case is apparently reported in part to show the connection between the disease of the liver and the xanthelasma. This does not seem to be made out; but the occurrence of xanthelasmic patches in the air-passages is of great interest, and militates against the view that xanthelasma is a merely local cutaneous affection.-ED.]

COLD AND WARM BATHS: THEIR INFLUENCE ON CUTANEOUS SENSIBILITY. - Stolnikow (Cbl. f. Chir., 1879, No. 32; from