Pennsylvania Hospital.—Surgical Wards.—Service of
Dr. Norris.
Cases discharged from November 1st, to December 1st, 1849.
Cured.	By request.	Died.
Abscess,.........................1	0	0
Burns,	1	0	1
Caries...........................1	0	0
Concussion of brain,	0	0	1*
Conjunctivitis, «	-	-	-	1	0	0
Contusion, -	-	-	-	2	0	0
Diseased bladder,	1	0	0
Dislocation of elbow,	1	0	0
Fractures 27, simple 22, viz. :
Arm...........................1	0	0
Calcis,.......................1	0	0
Clavicle,	-	-	-	-	1	0	0
Forearm,	.	-	-	.	7	0	0
Hand, -	-	-	-	-	1	0	0
Jaw, lower,	-	-	-	1	0	0
Deg.................................. 0	0
Patella,......................1 CO	0
Rib,..........................1	0	0
Skull,........................ 0	0	2t
Thigh,........................2	If	0
Fractures, compound, 5 viz.:
Finger,.......................1	O'	0
Foot,.........................1||	0	0
Leg,..........................2	0	0
Skull,........................1	0	0
Gonorrhoea, -	-	-	-	2	0	0
Inflamed hand,	4	0	0
Do. knee,	1	0	0
Paronychia,	3	0	0
Retention of urine,	1	0	0
Scrofulous disease of testis,	0	1	0
Swelled testicle,	1	2	0
Sprain,..........................1	0	0
Syphilis,	....	5	0	0
Ulcers,..........................1	0	0
Wounds 11, viz.:
Gunshot,	....	4	0	0
Incised, •	-	-	-	2	1	0
Lacerated,	....	4	0	0
Punctured,	1	0	0
G2	5	4
* Of abscess of the brain.
+ One of abscess of brain.
| Of neck of femur.
|| By amputation.
A case of dislocation backwards of both bones of the forearm,
without fracture, very similar to that reported in the May number of
the Examiner, 1849, has been discharged within a week or two. The
patient, a lad 12 years of age, was suddenly pushed over a carpen-
ter’s bench, striking his elbow as he fell. He was immediately
brought to the hospital. The luxation was very evident, but after
a close examination no fracture could be detected. As in the case
above alluded to, the olecranon was found some distance above
its usual position, the forearm was semi-flexed, the patient unable
to bend the joint and complaining of pain when any attempt was
made to extend the forearm, while anteriorly the lower end of the
humerus could be felt apparently projecting over the joint.
From pain and fright the boy had become nauseated, the mus-
cles were thus much relaxed, so that reduction was readily effect-
ed by placing the knee at the elbow joint, making gentle traction
at the wrist, and by bending the forearm. The bones glided into
their place with a snap and the deformity was at once corrected.
A roller commencing at the hand was carried up the arm, and an
angular splint applied to its anterior surface. Little or no inflam-
mation followed the injury. In a few days the splint was laid
aside, slight motion of the joint made, a sling substituted, and in
eight days the boy went out with full motion of the articulation.
As above stated, the lad believed his elbow to have been struck
as he fell; this may have been the case, though it is not improba-
ble that in falling, the hand was put forward to protect himself,
and the injury thus received, the luxation being, it is said, some-
times produced in this manner.
Three fatal cases of fracture of the skull are reported. The
first of these was that of an Irishman aged 32 years, whose head
was crushed by two rail road cars, which he was stooping to
detach, having been suddenly forced together. He was brought
to the hospital in a dying condition, and expired in about an
hour. The appearance presented by his head w7as some-
what peculiar. There was no external wound communicat-
ing with the skull, the fracture being a simple one, but a distinct
ridge of bone could be felt along the whole length of the parietal
and part of the frontal bones, these having evidently yielded at
their sutures, an opinion confirmed by a post-mortem examination.
By this was ascertained the existence of a comminuted fracture
of the temporal bone of the left side and a complete overlapping
of the parietal bones at their mesial line.
In the second instance, the man had fallen from the upper
story of a high building, striking a ladder as he fell, by which the
violence of the fall was somewhat broken. When brought to the
hospital he was laboring under symptoms of concussion of the
brain. His head was severely bruised, his left eye much swelled
and ecchymosed, but there was no external wound, no paralysis
and no insensibility to light. Hemmorhage from the nose, and it
was believed a slight bleeding from the ear, took place at the
time of the accident.
Cold to his head, warmth to his feet, perfect rest, the use of mer-
curials, occasional cupping and strict attention to his diet, consti-
tuted his treatment, under which he improved rapidly. On the
eighth day after his injury he appeared decidedly convalescent, his
intellect perfect, and free from pain in the head. During the after-
noon he imprudently ate some cakes and candies brought by his
friends, and in the night was attacked with severe pain in the
head and stomach followed by nausea and vomiting. These symp-
toms continued throughout the night and in the morning the
patient was found slightly convulsed, and with increasing dullness
of intellect. His bowels were freely moved by cathartics and
enemata, cups were applied to his head, and a large blister to the
nape of the neck. He continued to grow worse, involuntary dis-
charges of feces, total loss of his faculties, paralysis and frequent
convulsions followed, and the man died two days subsequently.
Much to our regret, permission to examine the body was posi-
tively refused.
In this case it is possible that the crude food taken, may have
been an immediate exciting cause of cerebral disturbance, in a
brain already diseased, though there was little doubt of a fracture at
the base of the cranium, and that an abscess of the brain had been
insidiously forming.
In another, somewhat similar case, that of an Irishman, aged
28 years, who had fallen through a hatchway, on the side of
his head, the symptoms of injury at the base of the brain were
almost unequivocal from the beginning. When brought to the
hospital he was found bleeding from the nose and ears, and with
entire loss of intellect. Partial paralysis was subsequently de-
tected. His treatment was in the main similar to that above men-
tioned, varied to meet particular indications. A gradual improve-
ment followed, the paralysis somewhat abated, his intellect im-
proved, though he never fully recovered the possession of his
faculties. A few days before his death, he complained of severe
pain in his head, and a sero-purulent discharge from his right ear
took place. One or two paroxysms of noisy delirium, and an increase
of paralysis, followed, and the man died on the 29th ult., a fort-
night after the accident. His death was somewhat sudden, he
having been seen but a few minutes before, apparently no worse
than on the preceding day. A post-mortem examination of his
head was made, by which was found a fracture of the squamous por-
tion of the right temporal bone and a large coagulum pressing
directly on the brain. This last having been removed, a well marked .
impression was left on the substance of the brain. On removing the
cerebral mass, a fracture of the petrous portion of the temporal
bone was discovered. At the base of the brain, at a point imme-
diately above the fracture, as if caused by the irritation of the
rough edges of the broken bone, was found a large abscess, ex-
tending to the lateral ventricle, and full of fetid pus.
An Irish labourer, aged 48 years, entered the hospital on the
14th of September, having fallen on his feet from a ladder ten or
twelve feet high, fracturing his left os calcis. There was but
little deformity, but he complained of pain when the foot was
moved, and the two fragments of bone could be distinctly felt
grating against each other, upon slight lateral motion.
The leg was placed in a fracture box, and the foot supported by
the foot board. Considerable tenderness and sw’elling followed,
which abated under the application of cooling lotions. Union
took place slowly, but satisfactorily. At the end of five wreeks
the box was laid aside, and a figure of eight bandage applied over
the instep and heel, in such a manner as to aid in retaining the
uniting fragments, and a week later the patient was permitted to
rise. Several days elapsed before he could bear any weight on the
foot, but by the aid of crutches, he so improved as to be able to go
out, walking without difficulty, about eight weeks after the receipt
of the injury.
This accident is spoken of by all surgical authorities as
one of rare occurrence ; the experience of the hospital coin-
cides with this statement, no other case of this fracture having
been treated here for a long time. South, in his edition of Chelius’
Surgery, quotes two or three cases of this accident. In one of these
the posterior part of the bone was drawn up to a considerable ex-
tent, by the action of the gastrocnemii muscles. I find a some-
what similar case reported in the American Journal of Medical
Sciences, for 1829, (page 129). In this the bone “ was fractured
just below the tendo acbillis, and the posterior portion was drawn
up as high as five inches from its former position.” The patient
recovered, though with deformity, the displacement of the bone
never having been overcome. A case very like this was, I be-
lieve, under the care of Dr. J. Rhea Barton, several years since.
Londsdale, in his treatise on fractures, has described a very inge-
nious apparatus for treating this accident, especially when deformity
exists. In the case above described, the injury to the soft parts
was less than usually happens, and the posterior fragment was not
drawn upward, being no doubt retained in its place by the inferior
calcaneo-cuboid ligament. The fracture was oblique, and a little
posterior to the middle of the bone. No other treatment was here
required than rest, the fracture box and a roller.
The four patients with gun-shot wounds, referred to in the last re-
port, have since that time been discharged, all of them apparently
in good health.	James J. Levick, Resident Physician.
Pennsylvania Hospital December, 1849.