[Reprinted from The Medical News, December 17, 1892.] 
THREE CASES FROM PRIVATE PRACTICE. 
By W. T. 
OF WEST CHESTER, PA. 
THE DIFFICULTY OF LOCATING BRAIN-LESIONS, AS 
ILLUSTRATED BY DEPRESSED FRACTURE OF THE 
FRONTAL BONE. 
On October 6, 1891, I was called to see a boy, eight 
years old, who had been kicked by a horse, receiving a 
compound depressed fracture of the frontal bone. There 
was a triangular tear of the scalp over the right eye. On 
raising the flap, the depression was found to extend from 
a point half an inch above the external angular process 
of the frontal bone, obliquely upward and toward the 
median line, a distance of one and a half inches. It 
was half an inch in width, and about one-eighth of an 
inch in depth. There was very little splintering of the 
adjacent bone. The boy was in good condition, and 
had not been unconscious. 
On consultation with Dr. Jacob Price, it was decided 
to trephine and raise the depressed portion. Before we 
operated, the patient had two convulsive seizures, the 
muscular movements being strictly confined to the left 
side of the face and neck and left arm. With a one- 
inch trephine, a piece of bone was removed above and 
overlapping the depression. The dura had not been in- 
j ured. The frontal sinuses not being developed in a child 
of eight years, we had no difficulty from that source. 
The injury to the internal table was much more exten- 
sive than that to the external table. With a lever the 2 
depressed portion was elevated, and the loose fragments 
removed. The tissues of the scalp were then replaced 
and the wound closed. The boy had no more convul- 
sions, and made a satisfactory recovery. 
I have reported this case because it seemed to me 
noteworthy that a wound in the frontal region should 
produce the motor symptoms described. If we had 
been operating for these symptoms alone, and had not 
had the external wound to guide us, we would have 
trephined over the motor centers of the parts convulsed, 
which are fully two and a half inches from the point of 
injury. The possibility of having the irritation trans- 
mitted for a considerable distance may explain some 
failures in brain-surgery, and lends an additional element 
of doubt to the exact location of brain-lesions. 
ANGINA PECTORIS IN A FEMALE, WITH OBLITERATIVE 
ENDARTERITIS OF THE ANTERIOR CORONARY ARTERY, 
AND AN AREA OF ANEMIC NECROSIS IN THE HEART- 
WALL. 
About January i, 1892, I was called to see a woman, 
sixty-two years old, who was subject to spells of severe 
pain in the precordia, radiating to the left shoulder and 
arm. The attacks occurred at variable intervals of time, 
not oftener than once a month at first, and were generally 
induced by exertion. The first attacks lasted but a few 
seconds. They gradually became more frequent and 
more prolonged, and occurred at times when there was 
no apparent cause. Between the attacks the woman 
had dyspnea on exertion and edema of the lower 
extremities. The heart-sounds were feeble, rapid, and 
irregular. The first sound was accompanied by a soft 
blowing murmur, heard best at the apex. The periph- 
eral arteries were not rigid. 
The heart-tonics, digitalis, strophanthus, and caffeine, 
increased the number and intensity of the attacks, as 
well as the general distress. The woman could tell 3 
with great accuracy that the " medicine made her 
worse," whenever any of those named was used. 
Amyl nitrite had very little effect on the attack, 
and that effect was soon lost. Morphine and atropine 
alone helped her. They relieved the attacks, and pre- 
vented their recurrence. The woman's general condi- 
tion gradually became worse, although the original 
attacks seldom occurred during the latter part of her 
illness, as she was kept constantly under the influence 
of morphine. She died suddenly August 9, 1892. 
At the autopsy the heart was found dilated and flabby. 
The mitral ring admitted four fingers. There was no 
thickening or retraction of the valves and no calcareous 
plates about the origin of the aorta. The anterior coro- 
nary artery was occluded, and in an area supplied by it, 
in the wall of the left ventricle near the apex, involving 
the whole thickness of the heart-wall, from the visceral 
layer of the pericardium to the endocardium, there was 
a collection of necrotic tissue. The endocardium was 
perforated, and some necrotic material was in the left 
ventricle. 
I have reported this case because anemic necrosis of 
the heart is not a very common condition, and because 
the symptoms during life, as well as the post-mortem 
conditions, render the diagnosis of angina pectoris allow- 
able, although Osler says that the disease occurs " almost 
exclusively in men." 
A CASE IN WHICH A MAN SWALLOWED A PLATE 
FOR ARTIFICIAL TEETH. 
On October 9, 1892, a patient came to my office, who, 
while eating his dinner, had swallowed a plate for arti- 
ficial teeth. The plate had originally carried two 
incisor teeth, but the teeth having come out he had 
worn the plate for several years because he had be- 
come accustomed to it. He complained of severe 
spasmodic pain in the region of the cardiac orifice 4 
of the stomach. A soft stomach-tube was passed 
and was arrested at about this situation, not entering 
the stomach. As the plate was too low down to be 
grasped by instruments, I gave him apomorphine, 
gr. %, hypodermatically, with mustard-water by the 
mouth (which he swallowed without much difficulty); 
but copious emesis failed to dislodge the plate. Then, 
with a stiff esophageal bougie, I pushed the plate into 
the stomach. The pain was almost instantly relieved. 
The " potato treatment " was adopted, and in forty- 
two hours from the time of swallowing the plate it was 
passed per rectum. The sharp edges slightly lacerated 
the anal sphincter. Otherwise no harm was done. 
The dimensions of the plate are iX by by % 
inches, as shown in full-size cut.