SUBACUTE GANGRENE RESULTING FROM INFLAMMATION OF THE INGUINAL GLANDS
A. B-, aged forty-two, first dislocated his shoulder in November, 1889. Traction on the arm and the heel in the axilla failed to reduce it, although the patient says that considerable force was employed and repeated attempts made. It was finally reduced by this means under chloroform ; Kocher's method was not used. In July, 1890, five days after, he came to me with a subcoracoid dislocation of the right shoulder. Employing Kocher's method, and without an anaesthetic, it was immediately reduced.
... mmediately reduced. Again, in September of this year, while on board ship, and during a storm, it again became dislocated. The ship surgeon employed traction, and, in spite of prolonged efforts, did :not succeed in reducing it. The patient explained to him the success that had attended Kocher's process, but it was not employed, and subsequently unavailing efforts were made by traction at a right angle and the heel in the axilla, the patient meanwhile being lashed down. Chloroform was not administered. On landing here twenty-five days afterwards, I tried Kocher's method, but as I did not try to induce extreme outward rotation of the humerus, I failed to reduce it. There was a history of syphilis, and I hesitated to make continued efforts for fear of fracturing the humerus, as may happen with this method if it is employed in old ,people or in certain diatheses. However, with an anæsthetic it was easily reduced at the first attempt. I feel sure that if I had persisted in inducing extreme outward rotation it could have been reduced without an anaesthetic. The advantages of the process are great and manifold. In at least 95 per cent. of the cases it dispenses with the necessity of an anæsthetic—a very great consideration. It requires no assistant. It is perfectly logical in its application, and exposes the patient to a minimum of rough treatment. There is one point absolutely essential to the success of the treatment, and which is generally made too Iitt"e prominent, and that is that the elbow must be carried forwards over the chest, while the humerus is still in a state of outward rotation, and it will be found that before it has described an angle of thirty degrees it will have been reduced. After the reduction is supposed to have been effected, the hand should be laid on the opposite shoulder and the elbow made to press well in the epigastrium. If this can be done, the reduction is complete. Concordia, Argentine Republic. VIOLET H-, aged nine months, was brought to the hospital on Aug. lst, suffering from diarrhoea, sickness, heaviness, headache, and crossness. The stools, which I had the opportunity of seeing, were of a thick and yellow nature. The mother stated that the child had been listless and had refused food for ten days or so, but that the symptoms which caused her to bring the child to the hospital-' v.z , the severe diarrhoea and sickness-had only supervened on Friday, the 31st, although on the 30th the child had been miore than usually dull and feverish, and had slight diar-rhæa. When seen on Aug. lst the child appeared to be very ill ; the skin, though white, and not flushed at all, was dry, and felt hot ; the temperature was found to be 102°; the tongue was dry, slightly furred, but not particularly red at the tip. The abdomen was slightly tympanitic ; there -at t med to be no pain on handling it except on deep pressure, and no spots were discovered anywhere. On the 2nd the infant seemed worse, the temperature was 101 '5°, and the abdomen was more distended. Death took place on the 3rd. At the post-mortem examination held on the following day the heart was found to be normal, the cere. bral vessels slightly congested, and some fluid, slightly in excess, in the lateral ventricles. The kidneys and liver were normal. The spleen, bilobed, not enlarged, soft or congested. The stomach contained curds; the small intestine was red in the neighbourhood of Peyer's patches; these patches were inflamed and elevated above the surround. ing surface, and some of the lower ones were commencing to break down. The mesenteric glands were enlarged, and the solitary glands of thecaecum were abnormally promimnt; the rest of the large intestine was normal, and there was no perforation of the gut, and no peritonitis. On inquiry the drains were found to be defective, the watercloset not having sufficient water-supply, and being next to the living room. Another woman in the house was laid up with similar sy mptoms-namely, pain in the abdomen, head. ache, and diarrhoea. Also about the same time another child of the same woman, aged eighteen months, was brought to the hospital with symptoms precisely similar, except that there was no elevation of temperature. It had been taken ill on Sunday, Aug. 2nd, with diarrhoea and vomiting. It bad, however, suffered from whooping-cough since the winter, and had had diarrhoea in a mild form for three weeks. I thought this case was worthy of record, as I have only been able to find one recorded case of enteric fever occurring in an infant-namely, one aged six months. Dr. Maguire kindly examined the intestines with me, and declared them to present the typical lesions of enteric fever. It is a question whether the elder child, who made a rapid and perfect recovery, did really suffer from the disease. The close proximity of the defective drains, and also of a refuse bin, probably was a sufficient cause. Enteric fever may possibly occur oftener in infants than is generally supposed, since it is so seldom fatal; whilst the occurrence of spots is so infrequent, and intestinal disturbance so common.