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1085 passing through the superciliary ridge of the right side, entered the orbit, and extended through its floor as far as the ethmoidal fissure. The roof of the left orbit was loosened from its attachments, yet the eyes remained intact, and the nasal bones were involved, doubtless by contre-coup in the same injury. So extensive, indeed, was this that evidence of its effects was found in the middle fossa of the base, in the shape of a fracture, that ran through the sella turcica and dorsum ephippii, and involved both clinoid processes, and the membranes were everywhere unduly adherent. The surface of the brain was deeply suffused with blood, especially on the right side, and the superficial vessels of the hemi- spheres and sulci were enormously distended. Congestion was, in fact, everywhere observable, and the puncta vas- culosa were throughout abnormally numerous and pro- minent. The cerebellum and pons were also the seat of this congestion, and such being the case it was not considered necessary to extend the examination further. The other patient, an older man, fell from an opposite direction into the same ravine about the same time, and he escaped without a scratch, and still survives, I believe. The best explanation that I can suggest of this difference is, that one, the former, was only slightly inebriated, while the other was dead drunk. A Mirror OF HOSPITAL PRACTICE, BRITISH AND FOREIGN. ST. BARTHOLOMEW’S HOSPITAL. SIX CASES OF ENTERIC FEVER, WITH REMARKS. (Under the care of Dr. SOUTHEY.) IN this autumn’s severe epidemic of enteric fever thirty- three cases have been under Dr. Southey’s care, eight of these have died, eight still remain under treatment, the rest have been discharged to their homes or convalescent insti- tutions. Some particulars of these cases may be of interest. CASE 1. Delirium, ferox type; epistaxis sudden death. George R-, aged seventeen, had been in bed ten days before his admission, restless and delirious for two days. On admission he had sallow complexion, was excited and maniacal; temperature high; abdomen tumid, numerous rose spots, profuse diarrhoea, dark motions, pulse dicrotous. He took nourishment well; had epistaxis; his highest tem- perature was 104.5°, which occurred on the day of his ad- mission. He was treated with one cold bath and several tepid baths, without being tranquillised by them ; also had chloral and bromide of potassium, without apparent benefit, and four ounces of brandy. After three nights of complete insomnia, talking constantly, exciting himself violently, endeavouring always to liberate himself from those who were appointed to keep him in bed, and just after Dr. Southey had been examining him and remarking upon his feeble dicrotous pulse, he suddenly sat up in bed and immediately fell back dead. The necropsy showed deep and extensive ulceration of the bowels, so that he must have been ill much longer than had been stated. Remarks.-His death could not pathologically have been earlier than in the third week. His case confirms the old opinion of the fatality of the forms which commence most insidiously, the patient going about his work for the first fortnight of his fever. It also illustrated the delirium ferox type of typhoid, and had suggested an unfavourable prog- nosis from the first. CASE 2. Probable relapsing typhoid; broneho-pneumonia. George L-, aged fourteen, was admitted on Oct. 4th. Previous duration of illness doubtful ; about three weeks. No distinct spots, but diarrhoea, with tumid belly and en- larged spleen, on admission. At first no delirium. Dicrotous pulse. Temperature varying from 1014° to 1036° Pro- minent broncho-catarrhal symptoms. Fresh crop of spots after he had been in hospital seven days. Treatment by Nulla autem est alia pro certo noseendivia, nisi quamplurimas et morborum et dissectionum historias, tum aliorum tum proprias collect as habere, et inter se comparare—MORGANI. De Sed. eat Caus. Morb-. lih. iv. Proœmium. stimulants ; quinine and tepid baths whenever temperature reached 103°. These were not employed more than four times, as his temperature did not range high. His fever intermitted, and considerable improvement took place be tween Oct. 8th and 18th, in the supposed third week of his fever. His temperature then began to rise regularly to 102 6° towards evening, falling on the thirty-first, thirty- second, thirty-third, and thirty-fourth days to 96’ fur its I minimum. During this time he became delirious by night, and his cough was very troublesome, with abundant moist sounds in the chest and viscid muco-purulent expectoration. He was extremely weak, but the diarrhœa had ceased, and he continued to take nourishment well. On the forty-first day of his fever he passed into a low, muttering, and septic delirious condition, and died of asthenia on the forty-seventh day of his illness, his temperature rising steadily from 97° to 103 4° the twenty-four hours before he died. No necropsy was permitted. The case might possibly have been com- plicated by acute phthisis, but rose spots were observed, and it was probably a relapsing case of typhoid. Patient cer- tainly died of fever with diarrhoea, and extensive broncho- or catarrhal lobular pneumonia. Remarks.—This case illustrated the extreme difficulty sometimes experienced in distinguishing between enteric fever and acute tuberculosis ; the clinical features that lent most weight to one or other interpretation of the cae were often discussed at the bedside. In the present epidemic pul- monary complications were observed in distinct relation to the highest temperatures, a low form of lobular pneumonia occurring in a large proportion of the cases when the tem- perature ranged above 103°. CASE 3. Perforation; _peritonitis; death.-John W-, , aged twenty-one, a tall delicate-looking young man, was admitted September 12th with rose spots, a temperature of 103.4°, diarrhoea, and all the other concomitant symptoms of enteric fever. He was apparently early in the second week of the fever on his admission. Some remission of his fever took place on the ninth or tenth day of his illness, when his morning temperature was 99’5° and his evening maximum only 101’4°. Between the ninth and seventeenth days the morning remissions were well marked each day, his diar- rhoea was slight, easily controlled, and his pulse, although feeble and somewhat dicrotous, improved under stimulants. Between the seventeenth and twenty-first days the highest temperature reached appeared to be only 99’5°, his respiration averaged 20 a minute, his pulse ranged between 84 and 96. There were no serious symptoms. His motions were semi- solid, and he took his nourishment well. Beginning with custard, bread-and-milk, and eggs for a couple of days. On October 1st, that is the twenty-sixth day of his illness, he was allowed some boiled fish, which he took eagerly, for his tongue was clean and he craved for solid nourishment. Coincidently with this improvement in his diet unfor- tunately his temperature began to rise again between the twenty-sixth and twenty-ninth days; it did so gradually, moving slowly upwards a degree and a half to two degrees each day, until on the twenty-ninth it reached a maximum of 106°. Of course, when his temperature was observed going up, the fish was stopped at once; he did not take it more than twice, but the bread-and-milk and puddings were given and taken with appetite by him. The high temperature indicated further or deeper ulcera- tion of the bowels, or some complication, and in the alter- native of our being able to detect no complication, was fairly attributable to deep intestinal lesion. The bowels, how- ever, were neither loose nor confined ; his pulse was 108, and respiration not above 24. On the thirtieth day his tempe- rature fell 5°, and for the next three days oscillated between 100 5° and 103 4°. On the thirty-fourth and thirty-fifth days, although he expressed himself as feeling better, his counte- nance changed for the worse. The abdomen became tumid Mid tender. His temperature had fallen, varying between 100.5° and 98° ; respiration 18; pulse 92, feeble. The following day (thirty-sixth) his pulse, by its sudden rise in frequency and extreme thread-like feel, indicated some serious complication. Peritonitis had, it was thought, begun two days ago ; now it had evidently either extended or actual perforation had taken place. His respiration was shallow, 36 per minute, but his temperature rose to 103’8°, a circumstance which led to the hope that the peritonitis must be circumscribed as yet, since when there is extension the temperature generally falls below normal. The patient was placed under the influence of morphia without delay, and nothing but an occasional tea-

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1085

passing through the superciliary ridge of the right side,entered the orbit, and extended through its floor as far asthe ethmoidal fissure. The roof of the left orbit was loosenedfrom its attachments, yet the eyes remained intact, and thenasal bones were involved, doubtless by contre-coup in thesame injury. So extensive, indeed, was this that evidenceof its effects was found in the middle fossa of the base, inthe shape of a fracture, that ran through the sella turcicaand dorsum ephippii, and involved both clinoid processes,and the membranes were everywhere unduly adherent. Thesurface of the brain was deeply suffused with blood, especiallyon the right side, and the superficial vessels of the hemi-spheres and sulci were enormously distended. Congestionwas, in fact, everywhere observable, and the puncta vas-culosa were throughout abnormally numerous and pro-minent. The cerebellum and pons were also the seat ofthis congestion, and such being the case it was not considerednecessary to extend the examination further.The other patient, an older man, fell from an opposite

direction into the same ravine about the same time, and heescaped without a scratch, and still survives, I believe.The best explanation that I can suggest of this difference is,that one, the former, was only slightly inebriated, while theother was dead drunk.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

ST. BARTHOLOMEW’S HOSPITAL.SIX CASES OF ENTERIC FEVER, WITH REMARKS.

(Under the care of Dr. SOUTHEY.)IN this autumn’s severe epidemic of enteric fever thirty-

three cases have been under Dr. Southey’s care, eight ofthese have died, eight still remain under treatment, the resthave been discharged to their homes or convalescent insti-tutions. Some particulars of these cases may be of interest.CASE 1. Delirium, ferox type; epistaxis sudden death.

George R-, aged seventeen, had been in bed ten daysbefore his admission, restless and delirious for two days.On admission he had sallow complexion, was excited andmaniacal; temperature high; abdomen tumid, numerousrose spots, profuse diarrhoea, dark motions, pulse dicrotous.He took nourishment well; had epistaxis; his highest tem-perature was 104.5°, which occurred on the day of his ad-mission. He was treated with one cold bath and severaltepid baths, without being tranquillised by them ; also hadchloral and bromide of potassium, without apparent benefit,and four ounces of brandy. After three nights of completeinsomnia, talking constantly, exciting himself violently,endeavouring always to liberate himself from those whowere appointed to keep him in bed, and just after Dr.Southey had been examining him and remarking upon hisfeeble dicrotous pulse, he suddenly sat up in bed andimmediately fell back dead.The necropsy showed deep and extensive ulceration of the

bowels, so that he must have been ill much longer than hadbeen stated.Remarks.-His death could not pathologically have been

earlier than in the third week. His case confirms the oldopinion of the fatality of the forms which commence mostinsidiously, the patient going about his work for the firstfortnight of his fever. It also illustrated the delirium feroxtype of typhoid, and had suggested an unfavourable prog-nosis from the first. CASE 2. Probable relapsing typhoid; broneho-pneumonia.

George L-, aged fourteen, was admitted on Oct. 4th.Previous duration of illness doubtful ; about three weeks.No distinct spots, but diarrhoea, with tumid belly and en-larged spleen, on admission. At first no delirium. Dicrotouspulse. Temperature varying from 1014° to 1036° Pro-minent broncho-catarrhal symptoms. Fresh crop of spotsafter he had been in hospital seven days. Treatment by

Nulla autem est alia pro certo noseendivia, nisi quamplurimas et morborumet dissectionum historias, tum aliorum tum proprias collect as habere, etinter se comparare—MORGANI. De Sed. eat Caus. Morb-. lih. iv. Proœmium.

stimulants ; quinine and tepid baths whenever temperaturereached 103°. These were not employed more than fourtimes, as his temperature did not range high. His feverintermitted, and considerable improvement took place between Oct. 8th and 18th, in the supposed third week of hisfever. His temperature then began to rise regularly to102 6° towards evening, falling on the thirty-first, thirty-

second, thirty-third, and thirty-fourth days to 96’ fur its

I minimum. During this time he became delirious by night,and his cough was very troublesome, with abundant moistsounds in the chest and viscid muco-purulent expectoration.He was extremely weak, but the diarrhœa had ceased, andhe continued to take nourishment well. On the forty-firstday of his fever he passed into a low, muttering, and septicdelirious condition, and died of asthenia on the forty-seventhday of his illness, his temperature rising steadily from 97°to 103 4° the twenty-four hours before he died. No necropsywas permitted. The case might possibly have been com-plicated by acute phthisis, but rose spots were observed, andit was probably a relapsing case of typhoid. Patient cer-tainly died of fever with diarrhoea, and extensive broncho-or catarrhal lobular pneumonia.

Remarks.—This case illustrated the extreme difficultysometimes experienced in distinguishing between entericfever and acute tuberculosis ; the clinical features that lentmost weight to one or other interpretation of the cae wereoften discussed at the bedside. In the present epidemic pul-monary complications were observed in distinct relation tothe highest temperatures, a low form of lobular pneumoniaoccurring in a large proportion of the cases when the tem-perature ranged above 103°.CASE 3. Perforation; _peritonitis; death.-John W-, ,

aged twenty-one, a tall delicate-looking young man, wasadmitted September 12th with rose spots, a temperature of103.4°, diarrhoea, and all the other concomitant symptoms ofenteric fever. He was apparently early in the second weekof the fever on his admission. Some remission of his fevertook place on the ninth or tenth day of his illness, when hismorning temperature was 99’5° and his evening maximumonly 101’4°. Between the ninth and seventeenth days themorning remissions were well marked each day, his diar-rhoea was slight, easily controlled, and his pulse, althoughfeeble and somewhat dicrotous, improved under stimulants.Between the seventeenth and twenty-first days the highesttemperature reached appeared to be only 99’5°, his respirationaveraged 20 a minute, his pulse ranged between 84 and 96.There were no serious symptoms. His motions were semi-solid, and he took his nourishment well. Beginning withcustard, bread-and-milk, and eggs for a couple of days. OnOctober 1st, that is the twenty-sixth day of his illness, hewas allowed some boiled fish, which he took eagerly, for histongue was clean and he craved for solid nourishment.Coincidently with this improvement in his diet unfor-tunately his temperature began to rise again between thetwenty-sixth and twenty-ninth days; it did so gradually,moving slowly upwards a degree and a half to two

degrees each day, until on the twenty-ninth it reacheda maximum of 106°. Of course, when his temperaturewas observed going up, the fish was stopped at once;he did not take it more than twice, but the bread-and-milkand puddings were given and taken with appetite by him.The high temperature indicated further or deeper ulcera-tion of the bowels, or some complication, and in the alter-native of our being able to detect no complication, wasfairly attributable to deep intestinal lesion. The bowels, how-ever, were neither loose nor confined ; his pulse was 108, andrespiration not above 24. On the thirtieth day his tempe-rature fell 5°, and for the next three days oscillated between100 5° and 103 4°. On the thirty-fourth and thirty-fifth days,although he expressed himself as feeling better, his counte-nance changed for the worse. The abdomen became tumidMid tender. His temperature had fallen, varying between100.5° and 98° ; respiration 18; pulse 92, feeble. Thefollowing day (thirty-sixth) his pulse, by its sudden rise infrequency and extreme thread-like feel, indicated someserious complication. Peritonitis had, it was thought,begun two days ago ; now it had evidently either extendedor actual perforation had taken place. His respirationwas shallow, 36 per minute, but his temperaturerose to 103’8°, a circumstance which led to the hopethat the peritonitis must be circumscribed as yet, since whenthere is extension the temperature generally falls belownormal. The patient was placed under the influence ofmorphia without delay, and nothing but an occasional tea-

1086

spoonful of ictd water or brand,y-and-water was allowed topass his lips. He appeared to suffer no pain, and for thirtyhours there was neither nausea nor any vomiting. Gradually,however, his eyes became more hollow and deep-set, and hisface more Hippocratic. On the thirty-eighth day his bowelsbegan to act, and loose, offensive motions passed from him,and vomiting of green bilious fluid began. On the thirty-ninth day the vomiting continued, and the patient describedominous symptoms of extending peritonitis, pain uponmicturition, extending upwards over the abdomen anddownwards over his thighs. He spoke, too, of a sensation ofbubbling in his interior. He lived, or rather lingered on,five days more, maintained by sips of iced champagne,brandy, and beef essence, and by occasional nutrientenemata, and he was kept nearly, if not wholly, out of painunder the influence of morphia. For two days before hedied his motions were voided involuntarily through the sphincter ani, and his abdomen became much less hard andtumid. Latterly he vomited very little, and even craved forsome toast and butter twelve hours before his end ; but hehad a severe rigor, and his temperature rose to 103 6° shortlybefore death.The necropsy showed deep ulceration and perforation in

more than one place near the ileo-cæcum, and peritonitiswith considerable glueing together of the intestines.

Remarks.—The feature of interest was the prolongation oflife for ten days after the commencement of the peritonitis,for death usually follows within forty-eight hours of itsoccurrence. A question which it would be very importantto answer, is the effect of more solid nourishment in de-termining this complication. Solid nitrogenous food inenteric fever is allowed as soon as it can be safely given-i. e., when the tongue is clean, appetite has returned, andthe temperature is normal. It is far more reasonable tosuppose that complete healing and sound cicatrisation ofulcers in the intestines will be promoted by a return to solidfood than by a starvation diet. Fish and sweetbreads, eggs,custard puddings, and even mutton which has been twicecooked-first boiled and then baked,-are very easily solubleand assimilable articles of food. The physician must steerhis craft between the Scylla of starvation and the Charybdisof over-feeding ; above all things let him ward off flatulentdistension of the intestines.

[Pressure on our space compels us to hold over theremaining three cases until next week.]

ROYAL SOUTHERN HOSPITAL, LIVERPOOL.A CASE OF RAPIDLY-GROWING MELANOTIC SARCOMA UNDER

THE LEFT TEMPORAL MUSCLE, INVADING THECRANIAL CAVITY; DEATH.

(Under the care of Mr. T. W. RANSFORD.)J. N-, a rigger, aged forty-two, married, father

of four healthy children, was admitted for the secondtime on February 12th, 1878, into the Albert ward.About a month before Christmas, 1877, he noticed a littleswelling in the left temple. Two weeks after Christmas hewas seen at the Liverpool Eye and Ear Infirmary by Mr.E. A. Brown and Mr. Ransford. The left temporal region,bounded by the origin of the temporal muscle above and thezygomatic arch below, was uniformly distended, as if byfluid, under the temporal muscle. The swelling was pain-less, free from any symptom of inflammation, and pre-sented the feeling of deep fluctuation. An exploratorypuncture was made with a trocar and cannula, but onlyblood came away. It was then diagnosed as probably amalignant growth. On January 29th the man was admittedinto the Royal Southern Hospital, under Dr. Wollaston.Up to this time no swelling had been noticed in the leftorbit, but very soon after admission a little fulness began toappear ; but the man felt so well that he was discharged athis own request. In a few days, however (February 12th),he was readmitted very much worse. The tumour had in-creased in size, and the left orbit was now decidedly full, andthe left eye protruded, and he complained much of giddiness;he was ordered to take iodide of potassium, and to have anice-bag applied over the eye and temple. On Feb. 17th hecould not bear the ice-bag; complained of much pain;ordered to take chloral and bromide of potassium at night,and to have belladonna lotion applied over the growth. Twodays later four leeches were applied, and opium was added

to the mixture. Soon after this he again came under thecare of Mr. Ransford. The nature of the disease was thenvery evident, and it was seen that nothing could be doneb yond relieving pain, which was done by means of morphiainjections. The ophthalmoscope revealed nothing exceptgreat congestion of the retinal veins.On March 4th, pain increasing, the tumour growing fast;

the eye was so much protruded that the lids could not beclosed; the conjunctiva was congested and swollen. Forthe satisfaction of the patient a consultation was held, atwhich it was decided to try the effect of leeches again andiodide in large doses. On March 6th the leech-bites bled agood deal, but did not relieve him. Ordered hypodermicinjection of morphia, one-third of a grain thrice daily; tocontinue the iodide of potassium. On March 24th thetumour had continued to increase rapidly; the eyelids wereenormously swollen and congested, the conjunctiva waseverted and covered with scabs, which smelt offensively.The eye could be seen only with difficulty. The manwas only partially conscious; he had been confined tobed for a week, and was getting now miserably thin,and passed everything under him. The injections ofmorphia were now left off, as he seemed insensibleto pain. In the evening he became much worse; hewas quite unconscious; no reflex movements on touchingthe conjunctivse; breathing stertorous, muscular tremors,pulse imperceptible, skin bathed in clammy sweat; heseemed to be in articich mortis. On the 26th he was muchbetter, and was partially conscious. He recognised his wife,but did not speak unless spoken to. He passed all hismotions under him. There was very offensive odour fromthe left orbit. Carbolic acid oil (two and a half per cent.solution) on lint was applied over the eye. He remained inthis condition several days. On April 2nd he again becameinsensible, and had the same symptoms as on March 24th.Pulse 134; respiration 26. The temperature at 1.40 P.M.was 102° ; at 3.50 P.M. 105° ; and at 7.5 P.M. 106 .4°. He diedat 7.10 P.M. ; the temperature fifteen minutes after death(body undisturbed) was 107° ; ward temperature 59° F.Necropsy (April3rd).-On removing the brain the middle

lobe on the left side was seen to be very much flattened, themiddle fossa of the skull on the left side was entirely filledwith a growth which had pushed the dura mater before it,in two or three places, however, having infiltrated andabsorbed it; the growth extended up the side of the skull,also under the dura mater, as far almost as the junction ofthe squamous portion of the temporal bone with the parietal.On removing the dura mater the base and side of the skullseemed to be occupied with a large dark clot of blood, it washardly as firm as blood-clot, but in every direction it wasintersected by very fine spiculse of bone ; it seemed to haveoriginated in the temporal fossa in the insertion of thetemporal muscle, to have absorbed the squamous portion ofthe temporal bone and the outer wall of the orbit, andgradually to have filled the orbit aud the cranial cavity tillthe gradually increasing pressure caused death from coma.A very good idea of its effect on the brain was obtainedby filling the cranial cavity with plaster-of-Paris beforethe removal of the dura mater from the base of the skull;this was given to the museum of the Liverpool School ofMedicine. The structure of the tumour was too diffluent toget any microscopical section of, only isolated cells could beexamined. It was seen from the first, from the situationand nature of the growth, that operative measures were outof the question.

NORTH - WEST LONDON FREE DISPENSARY FORSICK CHILDREN.-On Wednesday last, the 14th inst., thefirst general meeting of the dispensary, situate in Bell-street,Edgware-road, was held, George Hanbury, Esq., in thechair. A committee was formed, and it was resolved tocarry on the alterations now taking place over the presentdispensary, to provide wards and efficient nursing for chil-dren of the very poor of this densely populated district.The chairman offered f50 if three other donors will contributea like sum to the funds now being raised to accomplish thisobject. He remarked that there was but one hospital in themetropolis specially devoted to the treatment of diseases ofchildren, and was sure such an institution would be muchappreciated. He hoped the funds so urgently needed wouldbe forthcoming. The number of patients relieved during thetwenty years of the existence of the institution has beenabout 250,000. -