that she got relief by sitting up with the limbs hanging down, or by moving about gently on her crutches. The great pain was in hip and thigh, but at times it was severe in knee and ankle; it was worse during late fall, winter and early spring, better in the mild season; it was of a numb, darting and severe aching character, and was most severe at night, especially after lying quiet in the bed for some time. The two legs were of same apparent length."

The result of the examination was, that Doctors Hamilton and Jones agreed that there was no fracture, but found arthritis; in this judgment Dr. Warner did not concur.

Immediately after the result of the examination became known, the Plaintiff again had her cause continued at her costs.

About the 26th of Feb. 1886, the Plaintiff presented herself to Prof. W. W. Dawson, at Cincinnati, for an examination of her condition. The doctor made a careful examination, and in his deposition (which was afterward taken by the Defendant,) says, that he found her suffering "with chronic arthritis" of the hip joint. The Doctor was asked to state the symptoms existing, which led him to that conclusion. He answered:

"There was more or less pain on movement of the joint, and when the limb was moved it gave a sound something like two smooth bodies passing over each other, and again a sound not unlike the sound elicited by bending leather. It is what we call false crepitus.

The Doctor was asked if the books did not sometimes speak of the conditions named as "rheumatic arthritis," to which he replied: "Yes; the terms chronic rheumatic arthritis, or rheumatoid arthritis, are the terms usually employed; but I have never seen any reason why the term rheumatism should be used in this connection. The disease is but little like rheumatism, and most of the cases I have seen have resulted from injuries."

The following question was propounded to the Doctor:

"State whether or not, from the examination you made of Mrs. Henry's case, it is your opinion that a fracture of the hip joint had ever taken place.'

To which the Doctor responded:

"There was no evidence of it. I told her that her condition might have arisen from a contusion, or a slight impaction. There was no evidence of a complete fracture; we don't get bony union in the adult in this condition; on the supposition that there has been a fracture, the result would have been a very good one. In her case the neck of the bone was solid."

After the deposition of Dr. Dawson was filed in Court, the Plaintiff

sought and obtained leave to file an amended petition, averring injury to the ligaments of the leg, etc., etc., with the usual averments as to negli gence, &c. An answer was promptly filed to this new petition, and the cause was again continued at the costs of the l'laintiff.

The Plaintiff then presented herself to Dr. J. F. Baldwin, of Columbus. He made the following brief note of the case under date of April 9, 1886: "Had injury of right thigh two years ago last January. Right leg is somewhat atrophied and flabby-% in. shortening, as determined by measuring from ant. sup. spin. process to int. mal., and also by Bryant's triangle. Crepitation at hip on rotation, also on extension and flexion. Ligaments about joint seem relaxed: can draw limb down, but it goes up as against a solid point of resistance, not as though against the capsular ligament. Regard the case as one like that of Reese's: interstitial absorption with some dry arthritis."

At the next term of Court, the case was again continued upon the application of the Plaintiff, and at her costs.

And at last, at the April term (1887) of the Court, the Plaintiff dismissed her case, absolutely, at her costs.

NOTE BY DR. J. F. BALDWIN.

At the request of Dr. Courtright, I add some points that would have been brought out had this case come to trial. I was honored by Dr. Courtright by being consulted early in the progress of the suit, and in support of the hypothesis-which I regarded as the only tenable oneof arthritis (traumatic in origin), I furnished him with the following quotations under date of Sept. 8, 1885.

Barwell ("Diseases of the Joints," Wm. Wood & Co., 1881, pp. 259, 260, 262) says: "Arthritis deformans, if mono-articular, is usually, if not always, preceded by local injury, varying from a bruise or sprain to a fracture or dislocation." * * * "The limb becomes rapidly wasted and the muscles flaccid : * at the hip the emaciation invades the buttock, flank and thigh." * * "Crepitation in the joint may

*

be detected; crepitation, evidently bony, and due to the absorption of cartilage." * * "It is to be remembered that of all joints the hip is most usually alone affected, indeed, the term malum coxae senile originates from that peculiarity. When moro-articular at the hip, the affection is often traumatic. The eversion of the limb, the shortening and the crepitus, are often a cause of embarrassment in diagnosis. If a person, of whom the surgeon previously knows nothing, but who has for some time suffered from arthritis deformans, come to him after a fall or severe blow on the hip, he will probably be at first led to diagnose intra-capsular fracture; and even when previous history

arouses a suspicion of other disease, he may find it difficult to assure himself that fracture does not also exist, for the two are by no means incompatible." The same writer mentions the same point, with means of differential diagnosis, on pp. 374-5, vol. IV., "Internat. Ency. of Surg." Wm. Wood, 1884.

Ranney ("Surg. Diagnosis," 3rd Ed., '84, p. 236) gives the following as "symptoms in common" of intra-capsular fracture and "chronic rheumatic arthritis with contusion:" "Both are associated with crepitus; loss of power and loss of voluntary motion; local pain in region of hip; swelling and possible ecchymosis; a history of an accident; advanced years; eversion of the foot." [Advanced years, while the rule, is certainly not without many exceptions.] "It Occas

Erichsen (Lea, 1878, vol. 2., p. 231) says: ionally happens that an individual laboring under this affection [rheumatic arthritis], meeting with a fall or contusion of the hip, presents signs of fracture of the neck of the thigh bone, such as shortening, eversion, with some crepitation perhaps, and inability to move the limb."

Gross, (Lea, 72, vol. 1, p. 1025) in speaking of intra-capsular fracture, says "The changes now described are sometimes closely imitated by those produced in the head and neck of the femur by a fall or blow on the hip, leading to interstitial absorption of the osseous tissue, and to shortening of the limb, with destruction of the articular cartilage and eburnization of the resulting stump, very much as in arthritic rheumatism. There is reason so believe that cases of this kind are not infrequently mistaken, both during life and after death, for fractures of the neck of this bone.” (p. 1077.) "The pain [in rheumatism of the hip joint], which runs down the front of the thigh, is dull, heavy and aching."

Hilton ("Rest and Pain") describes a branch of the anterior crural (p. 193) which goes to the hip-joint: thus accounting for a "sympathetic" pain, in hip-joint disease, along the course of the anterior crural. not find that any other anatomist has described this branch.)

(I canHamilton (Fractures and Dislocations," 1884, p. 439) gives a case

in which this form of disease followed a blow on the hip.

I was consulted by the plaintiff April 9, 1886, and Dr. Courtright has given the result of my examination. April 29, 1885, I wrote as follows to her physician:

Dear Doctor.-I failed to get the authorities I wanted in Philadelphia, and only received them yesterday from Washington.

I think your patient is suffering from the effects of monoarticulararthritis and interstitial absorption of the femoral neck.

We discussed that aspect of her case when you were here, but the question of time stood in the way of your accepting that hypothesis.

Paget (British Med. Jour., Feb. 19, 1870, p. 183) says the shortening, from interstitial absorption, comes on "weeks or months after a contusion of the hip."

In the case of Haire vs. Reese (McClelland, Civil Malpractice p. 292), the plaintiff sustained an injury of his hip Feb. 2. Dr. Reese made his last visit May 10. "On or about the sixth of August following, the plaintiff called upon Dr. Agnew [D. Hayes] at his office. Dr. Agnew then observed that there had been some shortening of the leg. When asked by Dr. Agnew when that shortening had commenced, he replied that it was after he had got up to go about on crutches.' " The time here, until Agnew saw him, was six months and four days.

Durham (London Lancet, Dec. '70) reports a case of interstitial absorption following injury, in which the process had advanced so far in three weeks as to result in spontaneous fracture. No post mortem examination, however, was held, hence his diagnosis was not confirmed. Gulliver (Edin. Med. Jour., vol. 46, pp. 97 and 313) reports several cases of this interstitial absorption.

Case I. A boy, aged 15, "nine weeks" after the injury presented himself for examination: "the affected limb was at least half an inch shorter than the other." "Some months * * * after the limb had become considerably shorter."

Case 2. Aged 45. "On the 31st day *** he was out of bed, and walked across the room with the assistance of a stick; and in three weeks more he was walking about the hospital with tolerable ease. Previous to his dismissal it was observed that the injured limb was shorter than natural; * * * the shortening was found to amount to about one half an inch."

Case 3.
Case 4.

Time of appearance, and amount, of shortening not stated. Time of appearance not stated. 11⁄2 in. of shortening found at autopsy three years after injury.

In commenting on this subject, the writer says: "The rapidity with which the neck of the thigh-bone may be diminished, receives illustration from a case of fracture of this part recently described by Mr. Howslip, in which the neck had lost half an inch of its length by absorption on the third week after the accident."

The above cases show that seven months would be ample time for a shortening of % in., or even more.

As to the arthritis, I need only refer you to Hamilton (Frank), Gross and Barwell, for statements as to its liability to occur after contusions, and also as to the frequency with which such cases are mistaken for fractures. Very truly yours,

J. F. BALDWIN.

22.

A. J. Learned, M. D., Millfield, O.

On March 22, 1887, was called to see J. R. W., a blacksmith, aged He was suffering from a rather severe attack of mumps, and thinking to "reduce the fever," had taken what was supposed to be about. six grains of sulphate of quinine, a half or three quarters of an hour before I saw him. He was suffering with symptoms precisely similar to those of a severe paroxysm of asthma, and an urticarious eruption over the whole body. He informs me that this is the third time that quinine has affected him in this way, and that a cousin never can take it without suffering in the same manner. The urtication was described as being extremely severe and beginning about half an hour after taking the quinine and continuing for five or six hours.

In volume I, page 447, of the Ohio Medical Recorder (March 1877), Dr. R. M. Denig, of Columbus, gives a report of a precisely similar case, together with a translation of a case from a French journal. This effect of quinine is rare, the above cases being the only ones on record, so far as I know. Bartholow in the fifth edition of his Materia Medica and Therapeutics, pages 175 and 176, refers to the action of quinine being sometimes attended by an eruption of the skin, but says; "There is in fact no constant and invariable eruption, and many of the reported cases are open to the suspicion that the appearances on the skin are merely accidental and not causative."

In the cases above mentioned, the symptoms were the same in all, followed speedily the ingestion of quinine, never failed to follow its use after the idiosyncracy was developed, and were never known to occur at any other time.