On the Pathology of Uræmia and the Socalled Uræmic Convulsions*

self; back very muclhcurved and head sunk down. When in bed, always lies with her legs drawn up on her body." I take the following from the Case-book, under date July 31st. " Has been just about the same since last entry, not any worse ; and of late has been up, as a rule, during the day. Soon after 5 o'clock this morning, the assistant medical officer was summoned to see her, as there appeared to be something the matter with her left arm. She had complained of its hurting her to the night nurse at her last visit'at 5 A. M. On examination, the left humerus was found to be fractured obliquely at the lower third, the upper point of the lower fragment being nearly through the skin. The patient stated that she did not know how it was done ; that she did not feel anything wrong with it till towards morning, when it felt painful, and she told the night-nurse that ' something had come to her arm'. She had not hurt it that she knew of, and no one had done anything to her. The night-nurse said that she had been very frequently into the dormitory (containing four beds) during the night, as there was a patient very ill in it. H. N. had not complained till her visit at 5 o'clock. The only further fact elicited by inquiry was that the previous evening, between 7 and 8 o'clock, while one of the nurses, assisted by a patient, was conducting H. N. from the day-room to the dormitory, the patient helping tripped and fell; and in consequence of this H. N. fell over on one side, but she did not appear hurt in any way, and made no complaint while being taken to the dormitory. Another nurse assisted her into bed; she did not notice anything amiss, and H. N. did not complain or seem in pain. The latter, when asked about the fall in the passage, said she recollected it; that it was quite accidental, and she did not recollect being hurt then ; and repeated that it was not till it was getting light that she felt anything wrong with her arm. The fracture has been put up in the usual way; but owing to the general deformity, and also to the obliquity of the fracture, more than usual difficulty was experienced in doing so.-August 5th. Going on as well as can be expected. Was kept in bed for a few days, but gets up now and sits in an easy chair. Is very restless, and if not closely watched, interferes with the bandages.-August ioth. Up to last night, patient was going on very well, when a most extraordinary complication presented itself. About a quarter to 7, Dr. Deas was summoned to see her; that she had complained ofher left knee, with which there seemed to be something the matter. Dr. Deas found her seated on a commode in the dormitory, and at once discovered that the left femur was fractured nearly straight across, a few inches above the knee-joint. There was slight fulness, but no mark or discoloration of any kind. The charge-nurse of the infirmary said that a few minutes before she had wheeled H. N. along in her easy-chair from the day-room. She had then brought the commode and placed it close by the chair, and then she had lifted the patient up by her arm and shoulders and just shifted her from the easy-chair on to the commode. As soon almost as the patient was set down on the commode, she put her hand down and complained of her knee. The nurse looked at it, saw something was wrong, and sent for Dr. Deas. The latter had seen H. N. about 4 in the afternoon. She was then sitting in the easy-chair in the ward. She was as usual, and complained of nothing particular. When Dr. Deas saw her, the easy-chair was on the left inside the dormitory door, and the commode was touching it and at right angles, so that she could have been moved from one to the other with very little effort. H. N. herself said that she felt something give way in her knee all at once just as she sat down on the commode, and made no complaint of any roughness or carelessness. The patient was put to bed, laid on her right side, and the fracture put up by means of two lateral splints, the knee being bent and the thigh flexed. No difficulty was found in reducing the fracture and retaining the fragments in pretty good position. This second fracture occurring after the first, and in a situation where, -as a rule, fractures only occur from great direct violence or a fall from a considerable height, seems to point to only one conclusion, viz., that there is in this case that morbid condition of the.structure of the bones, under which thev are liable to give way spontaneously, or from very slight force or exertion." I need not enter into details as to the further'progress of the case. The patient did pretty well for a short time ; but extensive bed-sores then formed, broncho-pneumonia supervened, and the patient sank in about three weeks from the date of the second fracture. At the post mortem examination, the usual signs of broncho-pneumonia were present, and the heart was in a state of fatty degeneration. The diagnosis as to the condition of the bones was amply confirmed. The ribs were reduced to the thinnest shell of bone, as thin as paper, the interior consisting of very open cancellated texture, and dark soft grumous matter, which oozed out at each end when a portion of rib was squeezed between the finger and thumb, by which pressure the two surfaces could be approximated close together. The ribs, moreover, could be cut quite readily with a knife, either transversely or longitudinally, and broke with a soft rotten sort of fracture under very slight force.' I broke a portion of rib,'about one and a half inches long, in two by snapping it with the fingers of both hands, as one would break a piece of stick. There was no fracture of any of the ribs, nor of any of the bones, except the left humerus and left femur. On cutting down at the seat of these fractures, there was hardly any attempt at union, although a considerable quantity of soft rotten callus had been thrown out. The femur and humerus were in the same state as the ribs, the external dense structure being a mere shell, through which I pushed a. scalpel quite easily, the interior being composed of very open cancelle and matter similar to that in the ribs. I have not myself had an opportunity of witnessing the degree of degeneration of the osseous structure, which has been found in some of the recorded cases of extensive fractures of the ribs, etc.; but if it were anything approaching to the state of matters in this case, one could not be surprised at any amount of fractures, especially if the patient had been at all restless or violent, and without supposing that there had been the least ill-usage or undue violence. The moral of our case is very plain. Had this poor woman, instead of being quiet and helpless, been a recently admitted case labouring under acute mania, restless, violent, knocking herself about, rendering holding and a certain amount of restraint necessary on the part of the nurses, and even occasional struggles probable, she must have sustained numerous fractures ; and probably, at the post mortem examination, more than half her ribs and her sternum would have been found broken. As it was, there could not be the least suspicion that the fractures were due to violence of any kind; indeed, helpless as she was, requiring lifting, etc., the whole state of her rotten ribs bears witness to the great gentleness with which she must have been habitually handled. In conclusion, I would venture one other remark. I think there is a tendency now-a-days in asylum treatment to trust too much to manual restraint on the part of the attendants; and also to allow acutely maniacal cases to be at large in a ward, where, if they are not roaming about, exposed to chance encounters with other patients, they are being " restrained" by two or more attendants holding them, certainly to the mutual detriment of tempers, not to speak of the risk to possibly diseased bones. Such cases, and especially if epileptics or general paralytics, are, in my humble opinion, treated on wiser principles, and are also much safer, in the quietness and security of a padded room ; and this I state as my deliberate opinion, even at the risk of being styled " an advocate of seclusion", or of being thought behind the age in the matter of treatment.