719

rigid and he could only just stand. His back was arched,his abdomen as hard as a board, his head retracted,the features drawn into a grin, but he did not com-

plain of actual pain. Attempts to feed him with a tube

only resulted in still more violent spasm, the whole bodybeing thrown into the position of opisthotonos. The spasmwas, indeed, so severe that the respiration nearly ceased,the patient becoming rapidly livid. Chloroform was atonce administered and the spasm passed away under com-plete anaesthesia. The jaw could then be opened and, a gagbeing inserted, the mouth was explored, but nothing abnormaldiscovered, with the exception of a pellet of chewed paper atthe back of the tongue. By means of a nasal tube a mixtureof milk, beef-tea, yelk of egg and brandy was passed into thestomach and retained, and fifteen grains of chloral hydratewere given in the same way. The child slept well for severalhours, the spasm of the abdomen and limbs being quiterelaxed and that of the jaw nearly so. On waking the boyseemed quite conscious but drowsy, and an attempt to feedhim in the ordinary way was made, but only with the resultof producing recurrence of the spasm and the necessity for thefurther use of chloroform. Vomiting occurred once, and for themoment the jaw spasm was relaxed, but rapidly came on again.The spasm of the trunk muscles was unaffected. There was no5’ela.xation of sphincters.On the second day after admission it was found possible

to feed by the mouth by sips sucked through the teeth,but this improvement did not last long, and again thefeeding tube had to be resorted to under chloroform andlarge doses of chloral administered, doses varying from tento fifteen grains being given at longer or shorter intervals asthe severity of the spasms required. This condition con-tinued until July 31st, the child becoming very thin, thesuperficial veins of the trunk being very prominent andgeneral cyanosis coming on at intervals. The pulse remainedfair; the temperature never rose above 99° and the bowelsacted. Steady improvement began to be noticed during thefirst week in August, and by degrees the general muscularspasm and finally the spasm of the jaw completely passedaway and the use of chloral could be suspended with safety.The patient made an excellent and complete recovery. Thecase was carefully watched and very judiciously handled byMr. Gordon Calthrop, the house physician, to whom most ofthe credit for the successful issue is due.

EASTERN FEVER HOSPITAL.TWO CASES OF GLANDERS.

(Under the care of Dr. COLLIE.)THESE two records of patients who died from glanders are

of considerable interest at the present time, when the diseaseis attracting much attention, and it is important to observethat both were sent to the hospital with the diagnosis oftyphoid fever, and this suggests the possibility of similarcases being treated at their own homes for that disease, whenreally they are examples of the much more serious one ofglanders. It will also be noted that the first patient was takeninto hospital in 1890, the second in August, 1891. We haverecently in an annotationl drawn the attention of the pro-fession to the dangers attending the prevalence of glandersin horses in various parts of the kingdom, and these casesfurther prove the necessity for much greater stringency onthe part of the Government in the treatment of horses suffer-ing from the disease. The great risk run by those attendingon the horses is shown in Case 2, where the effect of sneezingon the part of the horse appears to have been sufficient tocause inoculation in that patient. " There is only too muchreason to apprehend that not a tithe of the cases of glandersoccurring amongst horses in London and the provinces arereported to the sanitary authorities." It is a disease whichrigid supervision should stamp out. For the notes of thecases we are indebted to Mr. James Dickinson, late assistantmedical officer.CASE 1.—F. H-, a male, aged twenty-five years, was

admitted to hospital on Dec. 24th, 1890, certified as sufferingfrom enteric fever. History obtained on admission : Ailingfor some time. The patient was seized with shivering onDec. 17th and since the 19th had been delirious. On admis-sion he was delirious and was restrained with difficulty.Aspect suggestive of pneumonia, but no physical signs de-tected.

1 THE LANCET, vol. ii. 1892, p. 267.

Dec. 25th.-Bloo<ly matter in sputum ; no physical signsfound in chest. Throat generally reddened, hyper&aelig;mia overchest. Abdomen retracted ; no tenderness ; no diarrh&oelig;a.27th.-Physical signs of consolidation detected over right

back. Cough troublesome, with plenty of blood-stainedfrothy sputum ; a cloud of albumen in urine. The patientgrew weaker from day to day and wasted visibly. The coughwas incessant, the sputum blood-stained and copious. Thesigns of consolidation became more extensive over the rightback and appeared also on the left. Otherwise the man’scondition did not present any markedly new features till thedate of the following notes.

Jan. 5th, 1891.-Very prostrate, semi-conscious and in-clined to mutter. Could protrude tongue, but with great diffi-culty, when bidden sharply. Respiration very rapid; pulsealmost uncountable. All dejecta passed into bed ; there hadbeen seven motions in the previous night. Discharge fromnose and left eye ; the discharge from the nose had beenfirst noticed the day before ; it was then slight and watery ;it was now thick and copious. On making the man blow hisnose there appeared a quantity of yellow purulent matter anda large piece of tough membrane. Scattered over the trunkand limbs was a scanty eruption of papules, vesicles andpustules. One or two pustules had been noticed on the previousday. Each vesicle and pustule was surrounded by an areaof injected skin. They rapidly increased in size, so that in afew hours from their first appearance they were all sizes, fromthat of a pin’s head to that of a shilling. There were alsoseveral intense erythematous patches, all seated over joints.The joints themselves appeared to be unaffected. Deep-seated fluctuating swellings were detected in both calves andover one shoulder. No glandular swellings.

6th, 1.30 A.M.&mdash;Death.The course of the temperature throughout is shown on the

accompanying chart.Necropsy, fourteen hours after death.&mdash;Pericardium un-

altered ; heart dilated and laden with fat. Recent pleuraladhesions all over right lung ; a few adhesions on left side.Right lung nearly solid throughout, with extreme emphysemaat apex and anterior margin ; it had a very lumpy feel andwas of an intense deep-red colour, except where areas ofemphysema stood out, owing to the engorgement of thebloodvessels, a bright vermilion. The condition appearedfrom subsequent microscopical examination to be a mixtureof pulmonary apoplexy and lobular pneumonia. The left

lung presented a less degree of the same condition. Bothbroke down easily under the finger. The throat and larynxwere not remarkable ; nasal fossae not examined. The ali-mentary canal was examined throughout without noteworthyresult beyond extreme injection and catarrh of the small

intestine ; the normally solid abdominal viscera were all ofrotten consistence ; the spleen contained one large infarct ;the kidneys weighed 11&frac12; oz., were rather pale on section, butthe structure stood out with remarkable distinctness : underthe capsule was a layer of intense injection ; no pus in anyof the joints ; there were several collections of dirty-lookingpus seated in the substance of muscles, particularly the calfmuscles : when the skull-cap was taken off several loosecollections of pus appeared between it and the dura mater ;beneath the dura mater and the brain were several similarcollections ; there was universal injection of all the cranialcontents.

History subsequently obtained from the brother : Theman’s work was all amongst sick horses. He had "to put theballs down their throats, and had more than once been bittenso as to draw blood. He had been ailing for two or threemonths from headache, cough, loss of flesh and weariness,but his doctor had told him he was not ill enough to throwhimself on his club. He kept to his work, but with greatdifficulty, up to Dec. 17th. When he reached home on that

day his knees gave way under him, and he was put to bed.He did not rise again.CASE 2.-S. C-, , male, aged twenty-six years, was

admitted to hospital on Aug. 14th, 1891, certified as sufferingfrom enteric fever. The history brought with the patientwas that he had been delirious for some days. On admissionhis breathing was rapid, and physical signs of pneumoniawere at once searched for, but without result. No rash.There was a small pustule on the abdomen.

Aug. 15th.&mdash;Night. Breathing rapid and panting. Someimpaired resonance at bases, but no other physical signdetected over lungs. Heart : action very rapid ; no increase ofcardiac area ; no murmur. Patient semi-conscious. Urinepassed freely into bed. There was an eruption of pustuleseach surrounded by a red area distributed over trunk, limbs

720

neck and face. The pustules varied in size from that of apin’s head to that of a sixpence. From the appearance ofthe eruption glanders was at once suspected and fluctuatingswellings were looked for and several detected in the calfmuscles. No discharge from nose or eyes ; no cough; nodiarrhoea. The finger-joints of both hands and one elbow-joint were swollen and red.16th.-Eruption very copious. The individual pustules had

increased very much in size and some were larger thanshillings. Several large ones were broken in the centre and

17th. -1. 40 A.M. ; death. The course of the temperature isshown on the chart.

Necropsy, thirty-six hours after deccth.-Heart dilated andladen with fat ; muscular substance rotten. No pleuraladhesions. Lungs deeply congested and very oedematous;no consolidation. Kidneys weighed 16oz.; capsules moderatelyadherent. The cut surface had a purple-mottled hue, and thecortex could scarcely be distinguished from the pyramid.There was pus in the finger-joints and one elbow-joint.There were many intra-muscular and subcutaneous collections

seemed to be drying up. Blood had been effused into someof them and there were one or two large vesicles containingblood-stained serum. There were many fluctuating swellings,some deep-seated in the calf and arm muscles, some sub-cutaneous. There was a hard swelling as large as a filbertand crowned with a petechia in the glans penis. Urine wasdrawn off. by catheter for examination. It contained a densecloud of albumen. No discharge from nose or eyes ; noglandular swellings ; no fresh joints affected. At night thepatient became comatose, snoring loudly.

of pus. All the other important organs were examined withoutdefinite result.The following history was subsequently obtained from the

father. The patient, in addition to his work as shopman,had charge of some horses. A horse with discharging nosesneezed in his face five weeks before admission. Two dayslater the man complained of pains in his limbs, headacheand shivering. He did not take to his bed till a fortnight.before admission. The horse died before the man.

Reviews and Notices of Books.Geographical Pathology : an Inquiry into the Geographical

Distribution of Infective and Clintatic Diseases. ByANDREW DAVIDSON, M.D., F. R. C. P. Edin., late Visitingand Superintending Surgeon, Civil Hospital, and Professoiof Chemistry, Royal College, Mauritius. In Two Vols.Edinburgh and London : Young J. Pentland. 1892.

IN these two large handsome and well-printed volumesDr. Davidson essays a laborious and difficult task-viz., ageneral survey of the distribution of infective and climaticdiseases throughout the globe. "The object of this work,"the author says in his introduction, "is to sketch the geo-graphical distribution of infective and climatic diseases andto trace the influence of temperature, rainfall, altitude andsoil conditions on their prevalence, character and epidemicspread." Under the term "infective diseases" the writerincludes "miasmatic diseases, such as malaria; miasmaticcontagious maladies, such as cholera ; and the contagious dis-eases proper, such as scarlet fever. Climatic diseases include,amongst others, croup, bronchitis, pneumonia and rheumatism,which are either owing to, or are materially influenced by,metereological conditions." Organic diseases of the heart,kidneys and nervous system are only noticed in some excep-tional cases, where they seem to be influenced by climate.Malarial fevers in their endemic and epidemic forms

receive very full attention and their consideration occupiesa large portion of the work. Typhoid fever, dysentery,yellow fever, influenza, pneumonia and phthisis are dealtwith at length. Only those who have personally worked

in this field of inquiry can adequately realise the immensedifficulties which beset the task to which Dr. Davidsonhas addressed himself, difficulties arising out of scanty,imperfect and often untrustworthy sources of informa-

tion, different methods of registration, anomalies in medicalnomenclature and from other causes. The author says:"To determine the actual prevalence of any given disease-over an extensive area with any approach to scientific

accuracy is obviously, under present conditions, impossible.The utmost that can be attained is an approximate estimateof the relative prevalence of diseases in different countries.Fortunately, " he adds, "such a knowledge as is attainable inregard to most countries is not only full of interest to thestudent but of vast practical importance to the statesman, thearmy medical officer and the sanitarian." In some countries,such as Norway and Sweden, all cases of disease which comeunder the notice of the district medical officers are regularlyreported to the State authorities, who publish annual reports,which are accessible. This direct method of ascertaining

the prevalence of disease is obviously the best, but it is not

always available. The statistician is usually compelled toresort to such indirect methods as ’’ (1) the determination ofthe proportion of deaths from a given disease to a unit of the-population, or (2) the proportion of deaths from a givendisease to the deaths from all causes within a certain area,or (3) the ratio which each disease bears to the total treatedin hospitals, or (4) the reports of physicians who have-resided in, or of travellers who have visited, the less civilisedcountries as to the diseases they have observed to prevailamong the natives." Dr. Davidson prefers the first of theseindirect methods when available, and adopts it as often as