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record, and I gather from such details as are given withrespect to the places in which the mussels were found thatthey were in contact with sewage or stagnant water.Dublin.

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A CASE OF VERTICAL DISLOCATION OF THEPATELLA.

BY ED. A. PIGGOTT, L.R.C.P. & S. EDIN., L.S.A. LOND.

THE following case occurred in my practice some timesince. This form of dislocation being somewhat uncommon,and great difficulty having been experienced in its reductionin some recorded cases, are the principal reasons for mypublishing these notes, and, I think, make the case worthyof observation.Walter M-, aged thirty-two, an agricultural labourer,

when endeavouring to gain the high road from a field bymeans of jumping a ditch, alighted upon uneven ground,and, losing his footing, made a sudden and violent mus-cular effort to regain his equilibrium, in which he failed,and fell into the ditch, from which he was unable toraise himself. Fortunately help was at hand, and hewas conveyed to his home in the immediate neighbour-hood. On arriving at the patient’s cottage, some fourmiles distant from my residence, and making a carefulexamination, I found that the patella was dislocatedvertically-in fact, completely twisted round upon itsaxis, so that its internal edge was resting between thecondyles of the femur upon the trochlear surface of thatbone, its external edge projecting beneath the integumentin front of the knee-joint in a line almost directly forwards,but with a very slight inclination outwards. The man wasin extreme pain, and the slightest attempt at movement ofthe knee-joint caused intense agony. I endeavoured toreduce the dislocation by ordinary manipulation, but afterseveral attempts this proved impracticable. As, unfor-tunately, I had no supply of chloroform with me, Idecided to make a further attempt at reduction beforeprocuring it, especially as the patient was in a stateof semi-intoxication, which circumstance would necessarilyfavour my efforts. Having procured some stout towelling,I placed a clove-hitch round the ankle-joint, and with theaid of three powerful men made extension directly down-wards, at the same time raising the limb (the patient lyingupon his back on the floor) with counter-extension beneaththe axillae. During the period extension was being exer-cised I made considerable pressure on the outer edge of thepatella with my fingers and thumbs. Then suddenlyrelaxing the extension, I sharply flexed the leg upon thethigh, or rather my assistants did, at the same time keepingup the pressure upon the patella, when the bone slippedinto its normal position with a very audible " crack." Thelimb was then put up in a suitable splint, and a lotioncontaining tincture of opium combined with solution of sub-acetate of lead applied, ten grains of Dover’s powder beingprescribed internally at night. The local inflammatorymischief was very slight, and at the end of three weeks thepatient was able to walk with no other support than a stick.

Remarks.—I considered myself fortunate in reducing thedislocation, with, comparatively speaking, so little trouble.This I attribute principally to my having seen the case almostimmediately after the injury was inflicted, and to theefficient and unhesitating manner in which my untutoredassistants carried out my instructions.Clare, Suffolk.

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PILOCARPINE IN POISONING BY BELLADONNA.

BY WM. MCGOWAN, B.A., M.D.,MEDICAL OFFICER MAGHERA DISPENSARY.

ON Dec. 25th, 1889, at about 11.30 A.M., a messengercame for me to visit immediately Mrs. M-, aged aboutthirty-seven, who was said to be dying from having takena quantity of a liniment by mistake for a dose of a mixtureshe had been ordered. As the remains of the bottle werenot brought to me for inspection, I had no means of knowingor finding out then what the poison was. Taking withme a hypodermic case, stomach pump, &c., I arrived ather residence, three miles distant, shortly after 12 o’clock.I found, on examining the bottle, that the liniment was

linimentum belladonnas B,P., and that at about 8 A.M. shehad taken a large tablespoonful of it. Her condition was veryserious. She was totally unconscious, and breathing ster-torously ; there were frequently recurring convulsions ; thepupils were widely dilated, so thattherewas only a ringof iris,and they were not influenced by light ; the extremities werecold, the heart greatly excited and weak, and the pulsescarcelyperceptible at the wrist. She presented all the appearancesof approaching death. Some attempt had been made beforemy arrival to procure vomiting, but without success. Asshe could not swallow, I injected one-tenth of a grain ofapomorphine. This failed to produce vomiting, and, fearingthe depressing effect sometimes produced by the drug, I didnot repeat it, but at once introduced the tube of the stomach-pump, and thoroughly washed out the stomach. The stomachwas almost empty, and I could not detect any odour of bella-donna in the water returning from it. I then injected hypo-dermically one-third of a grain of pilocarpine, passed thecatheter, and withdrew nearly a pint of urine, injected apint of strong hot coffee into the rectum, and usedflagellation with a wet towel over the chest and cheeks.I also applied mustard to the calves of the legs. In abouthalf an hour improvement was observed ; her countenancebecame more natural. A little later she looked about her,and was soon able to swallow small quantities of sal volatileand strong coffee. At 2 P M. I left her, ordering the salvolatile and coffee to be continued alternately, and warningthe attendants against allowing her to sleep. At 5 P.M. Ireturned, and found her sitting up in bed in a rather ex-cited condition, and talking deliriously. She knew me, butdid not realise her position or know anything of what shehad passed through. I injected another third of a grain ofpilocarpine. It did not at any time produce perspiration,but only a little softness of the skin. From this timerecovery was uninterrupted. She complained of thirst anddryness of the throat, and remained very weak, being unableto get up for nearly a week.

Remarks.—I consider this case worth recording, on accountof the undoubted action of the pilocarpine in antagonisiing-the belladonna. Owing to the length of time from takingthe dose and my seeing her (over four hours), the poisonmust have been entirely absorbed, as, indeed, was clearfrom the absence of odour of belladonna in the washings ofthe stomach, and from the very marked and characteristictoxic effects. Although I used the stomach-pump, I can-not attach much importance to this part of the meansadopted. There can therefore be little doubt as to the effec-tive part played by the pilocarpine in the cure, and in pre-serving a valuable life to a large family of helpless children.Maghera, co. Londonderry.

SIMULTANEOUS FRACTURE OF BOTH CLAVICLES.BY W. H. BOGER, M.R.C.S.ENG., L.R.C.P.ED.

I MUST candidly admit that until reading Mr. Owen’sarticle in THE LANCET of July 5th I was unaware thatsimultaneous fracture of both clavicles was such a rareevent. Having, however, had a case quite recently, possiblyit may be worthy of record.

J. S-, a farmer, aged forty-five, was riding in a steeple-chase at the Fowey annual races, when his horse, which hehad failed to draw in soon enough to take the first fence, camewith such force against the hedge that it threw its rider,who, turning a complete somersault in the air, disappearedinto the adjoining field. The horse then turned, and,scrambling over after the others, slipped and rolled over ontop of its rider. I happened to be at the other end ofthe field, and so only saw the accident from a consider-able distance, and on arriving at the scene of the disasterfound they had dragged the man away from the spot wherehe had fallen to avoid the oncoming horses from doinghim anyfurther damage. I made inquiries as to the position &c. inwhich he fell, but could gain nothing definite, so thatwhether it was likely to have been done before or after thehorse fell on him I am not prepared to say. Unfortunatelyhe turned out a very tyrannical patient to have to deal with,for he would neither lie still nor keep the bandages on Iplaced round him, and finally insisted on going home fourdays after the accident, a distance of some thirty miles, in a,close carriage. The fractures on both sides were situatedabout the junction of the middle and outer third, and came

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into very fair positions when lying flat on his back on a hardbed with a pad in each axilla and his arms bandaged cross.wise in front of his chest, but as he persisted in having themfree, and would return home so soon after his misfortune,the probable results seemed somewhat lamentable. I haveheard once since from his wife, who informed me that thedoctor they called in had been obliged to put on straps (?)But I have written to him for more explicit details.Fowey, Cornwall.

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PSEUDO-XANTHOMA AND MORPHŒA ANDANÆMIA.

By ANGEL MONEY, M.D., F.R.C.P.

IN the remediable anaemias of middle-aged women I havenoted pale papular elevations on the eyelids as symmetricalas areas of xanthelasma often are, and having all the cha-racters, except the colour, of these buff-coloured plaques.When these are present the pigmented purplish discoloura-tions, especially of the lower eyelids, so common in nervousexhaustion have frequently been very marked. In fact,the combination of neurasthenia, anaemia, and a dark

complexion makes this sign of disease more striking thanany other combination known to me. It is in this class ofcase that the elevated lumps in the skin known as

morphcea may be detected on the limbs, generally thearms, of anaemic and nervous women. These lumps havenothing in common, in my experience, with true rheumaticnodules of subcutaneous or other distribution. I have notseen genuine valvular rheumatic heart disease in this con-nexion. The limbs affected were fat, and belonged towomen who, however "poor" their blood and nerves were,were certainly not wanting in fat in any portion of theiranatomy. I have never seen them in association with theanaemia, of phthisis or of saturnism, though I have speciallylooked for them during the last six years.Harley-street, W.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

PADDINGTON INFIRMARY.A CASE OF EXTREME ATROPHY OF THE SPLEEN WITHOUT

SYMPTOMS DURING LIFE ; REMARKS.

(Under the care of Dr. THOMAS SAVILL.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mor-borum et dissectionum historias, tum aliorum tum proprias collectashabere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb.,lib iv. Proœmium.

As age advances atrophy of the spleen is met with, Isimilar to that which affects other lymphatic organs, suchas the tonsils, the lymphatic glands, and the thymus. Not

infrequently atrophy of the spleen is found at an earlierage (in the adult), but as there are no symptoms bymeans of which its presence can be diagnosed, it is left tothe post-mortem examination to reveal its presence. It israre, however, to find it shrunken to such an extremedegree as in the case recorded below, if we may judge bythe few cases recorded in the Transactions of the Patho-logical Society of London. Dr. Gibbl exhibited a spleenwhich weighed only half an ounce removed from the bodyof a patient aged sixty-seven, who had died from exhaustion,the result of persistent diarrhoea, and referred in hisremarks on the case to other examples of extreme atrophy;to Dunglison, who met with a case in which the spleenwas reduced to the size of a small almond; to Portal,who wrote of one not larger than a nutmeg, and to Cruveil-hier, who had seen it weigh scarcely a single drachm. Dr.Richardson2 had a patient under his care with aneurysm ofthe c(LIiac axis of some years’ duration, and at the post-mortem examination the spleen was found to be not largerthan that of a child of six ; the age of the patient was

1 Trans. Path. Soc., vol. xiii., 1862, p. 245.2 Asclepiad, 1884, p. 112.

fifty-four. Dr. Parkes3 described a case, that of a managed thirty-two, who died with choleraic diarrhoea, in whomthe spleen was excessively atrophied ; here the atrophywas supposed to have resulted from repeated attacks ofinflammation. With regard to the causation of splenicatrophy, Dr. Bristowe4 writes: " In some cases it appears,like cirrhosis of the liver, to be consequent on an interstitialovergrowth of connective tissue ; in some, as also occurs inthe liver, to the investment of the organ in a dense andslowly contracting fibrous capsule."

i Harriet W-, aged forty-three, was admitted into thePaddington Infirmary on May 29th, 1890. She had beensuffering for some nine months from cough and shortness ofbreath, but had kept at work until three weeks beforeadmission. She had also suffered from night sweats andemaciation, but had never spat any blood. She was ad.mitted in a very emaciated condition, with the signs of veryadvanced phthisis affecting both lungs, but chiefly the left.Although the signs of tuberculosis were unmistakable, andthere were signs of extensive breaking-down in both lungs,the temperature was only 99° on the two evenings whichshe survived after admission- namely, on May 29th, at8 P.M., 99°; on the 30th, at 8 A.M., 99-8°; on the same day,at 8 P.M., 99°; on the 31st, at 8 A.M., 98-8°. The urine wasnormal, and the other organs presented no abnormal signs.She was somewhat anaemic, but not more than isusual in such cases, and the only feature which shepresented which at all departed from the usual courseof such condition, besides the absence of pyrexia, wasdelirium at night. The family history, so far as she knew,was free from any record of consumption. She had hadthree children, all of whom were living and healthy. Herprevious history, with the exception of a cough in thewinter for the last three or four years, had been free fromany ailment. She died on the afternoon of the third dayafter admission.

Necropsy.—The post-mortem examination was made byDr. Hillier seventy-two hours after death, and the followingis his report:-Pericardium: adhesions throughout, especiallyover the right auricle. Left pleura : A few adhesions downthe anterior margin and at the apex. Right pleura : Universaldense adhesions, which required dissection from the peri-cardium and diaphragm. Peritoneum natural. Heart:Weight 7?oz. Much decolourised clot in both sides of theorgan, more especially in the right ventricle. Most of theright auricle, pulmonary artery, and pericardium coveringthem were densely adherent to the lung. The valves werehealthy, except the mitral, which was a trifle thickened withsome recent gelatinous material. The aorta contained tracesof atheroma. The substance of the heart was pale andslightly friable. Right lung (28 oz.) : Upper lobe com-pletely riddled with irregular cavities, crossed by trabeculie,and containing brown purulent fluid ; very little pul-monary tissue left. The remainder of the lung presentedthe appearance of catarrhal pneumonia, studded withmiliary tubercles. Left lung (31 oz.) : Apex consolidated,containing an extensive deposit of tubercle". One cavitythe size of a filbert in the centre; scattered tuberclesin the lower lobe, which was oedematous and congested.The liver (45 oz.) was pale and fatty. Under the micro-s.cope it presented fatty degeneration and some cirrhosis.The kidneys (right 51 oz., left 4 oz.) were pale; capsuleslightly adherent in places; small cyst on the surface of theright kidney. Microscopically it showed some increase ofconnective tissue, otherwise normal. The dura mater wasnormal ; the arachnoid over the vertex was opaque andthickened to about twice the normal, and there was opaquelymph beneath it in places. The pia mater generally wascongested. No tubercles discovered after careful searchwith the microscope in the fissure of Sylvius or elsewhere.The spleen was only found after careful search. It was verysmall, weighing only 56 grs., and measuring 1-3 in. by 1/8 in.by 1/5 in. It was slightly adherent to the stomach, was firm ,

on section, and under the microscope presented some increaseof the fibrous tissue, but was otherwise normal. Nothingwas discovered which could throw any light on the atrophiccondition of the spleen.Remarks by Dr. SAVILL.-The normal weight of the spleen

varies between 8 oz. and 10 oz. (Quain), and its dimensionsaverage about 5 in. by 3 in. by 1 in. ; the spleen of thispatient was therefore about one-thirtieth the normal bulk.

3 Med. Times and Gaz., vol. ii. 1852, p. 637.4 Theory and Practice of Medicine, p. 567.