POTT'S FRACTURE BY DIRECT VIOLENCE
A ]liAN fifty years of age was admitted to the Bootle Borough Hospital on Nov. 7th, under the care of Mr. Wills. He had been working at the docks lifting iron bars, each weighing about 5 cwt., off a pile 4 ft. in height. He was standing close to the pile when one of the bars, accidentally loosened, fell to the ground, striking his right leg a few inches above the outer ankle, throwing him on his left side and pinning his right foot under him. When examined, bruising was noticed on the outer
... ed on the outer side of the leg at the point where the patient said he was struck, the ankle-joint being swollen, especially on the inner side; the foot was displaced outwards and slightly backwards, the fibula broken 22 in. above the tip of the external malleolus, and the end of the internal malleolus broken off-in fact, the condition known as Pott's fracture. The interest in this case is that the cause of the fracture is very rare, the same result being brought about by the direct violence of the bar striking the leg on the outer side just above the ankle as usually follows the indirect violence of the well-known street ankle-twist. The patient himself was very emphatic in the statement that the bone broke at the moment the bar struck him, and not owing to any attempt on his part to raise himself from the ground, the bruising found above the ankle on the outer side adding confirmation to this. Bootle. CASES of hasmoglobinuria are so comparatively rare that we have thought fit to put upon record the following case which occurred in our practice. The patient, a girl eight years of age, in comfortable circumstances, had previously enjoyed good health, and there was no history of a previous similar attack. When first seen she was suffering from dyspnoea, her face was puffy and she frequently had a desire to micturate, but six ounces of urine only were passed in the twenty-four hours. The onset of symptoms was rapid, the child having been quite well two days previously. At first the case was diagnosed as acute Bright's disease, although there was an absence of the " Bright" eye, a sign which has been called attention to more especially by Professor Grainger Stewart. The dyspnoea was thought to be due to urasmia, and it was only after the urine was examined chemically and microscopically that the true nature of the disease was discovered. The urine was chocolate-brown in colour and contained a coffee-brown sediment. When it was heated this brown sediment rose to the surface, giving a clue to the disorder that we had to deal with, for hemoglobin rises to the top when heated in a fluid, while coagulated blood cells fall to the bottom. On applying the guaiacum and ozonic ether test a blue colour was at once struck, showing the presence of bsemoglobin in some form or other. The microscope revealed no casts, only a few red cells entire, but the field was covered with masses of amorphous haemoglobin. A few red cells with the hemoglobin partly extruded, some transitional epithelium, and crystals of calcium oxalate were also seen. The absence of casts, the comparative absence of red blood cells, and the presence of a large amount of haemoglobin made the diagnosis certain. The acute symptoms soon subsided, the patient being convalescent in three days after the onset of the illness, although she was in a very anasmic condition. Day by day the urine was examined for casts, but none were found. A trace, but only a trace, of albumen was detected up to the eleventh day, after which the urine was normal. The hasmo-globin disappeared entirely after the fourth day. The treatment consisted in administering four-minim doses of tincture of digitalis four times a day till the dyspncea disappearedwhich it did by the end of the second day. The in tention was to produce diuresis and to strengthen the heart. Milk diet, diluents, warmth, and the recumbent posture were enjoined. The latter was necessary, for on one occasion, when the patient disobeyed orders and sat up, she fainted, most likely owing to the ansemia. After the brown sediment of haemoglobin had disappeared from the urine and a larger amount of urine was being passed the digitalis was stopped, and three-minim doses of Fowler's. arsenical solution were given four times daily, and in a day or two the anaemia disappeared and the child became quite rosy. The cause of the disease is obscure, but the watercloset pipes of the house had been leaking for a few weeks and a disagreeable smell was perceived, and at the time of the attack the leaking pipes were being taken up and replaced by sound ones, the smell being more than ordinarily disagreeable. It is possible that the inhalation of sewer air was thecause of the rapid and severe disintegration of the blood cells, for sewer air readily affects young children, and noxious. vapours cause hasmoglobinuria, although, as far as we areaware, no case has as yet been traced to the inhalation fii sewer emanations. Meanwood-road, Leeds.