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parent membrane, is firmly bound down to the ciliary body, of the cornea. The posterior elastic lamina, in these cases, where it increases in thickness, and goes under the name of in losing the support of the lamellated tissue in front, may the structureless membrane of Zinn (c), from its discoverer. often be observed to protrude through the bottom of the This union is effected by strong fibres which are given off ulcer in the form of a vesicle. This is caused by the disfrom the external surface of the latter, pass into the sub-tending force of the fluid within. The distending force stance of the ciliary body, and meet those, already referred of the vitreons body is illustrated by the pressure effects on to, coming from the posterior elastic lamina of the cornea. the central vein of the retina. In the normal state of parts Thus, then, these two membranes become united in the the central artery and vein of the retina, as they pass over ciliary circle, and form a structureless sphere, the function the optic disc, are raised above its surface, and are in direct of which is essentially that of limiting the humours which contact with the hyaloid membrane, even projecting someit encloses. For brevity of description I shall call this what into the substance of the vitreous. In such circumsphere the aqueous capsule of the eye. stance the artery does not show any signs of pulsation, but the vein does in many cases; and in all the latter is flatFIG. 5. tened by the pressure of the vitreous, and pulsation is easily provoked in it. Now, the pulsation of bloodvessels, in any case, arises from the resistance which the walls of the vessels or outlying structures give to the distending force of the blood. While, in the eye, therefore, the distending force of the vitreous humour is insufficient to compress the arteria centralis retina to that degree which will give rise to pulsation, it is sufficient to flatten the vena centralis retinæ, and to give rise to pulsation, or an intermittent current of blood over the optic disc. As the vein, in this case, is as much subjected to the pressure of the vitreous as if it were in the centre of the humour, an index of the distending force of that body is thus obtained, which may be roughly estimated as equal, or slightly superior, to the lateral pressure of the blood in the smallest veins.

(D).

Diagram of the Aqueous Capsule of the Eye.

A, Posterior elastic lamina of the cornea. B, Hyaloid membrane. c, Structureless membrane of Zinn. D, Union of the membranes of the two hemispheres in the ciliary body. E, Fasciculus of fibres which enclose the canal of Schlemm. F, Crystalline lens. G, Ligament of the anterior capsule. H, Ligament of the posterior capsule.

The parts contained within the aqueous capsule are, the aqueous humour, iris, crystalline lens, and vitreous humour. It is divided into two segments by the lens (F) and its ligaments (GH); but the division is such as to admit of a certain amount of imbibition between the two hemispheres. This latter fact is of the less importance, as the fluid in the two hemispheres is chemically and physically alike, comes from the one source, distends both hemispheres with an equal degree of force, and its amount in both is regulated by the same principles.

The vitreous tissue in the posterior segment, and the posterior elastic lamina of the cornea in the anterior segment, confer upon the aqueous capsule the property of elasticity in a high degree, so that it is able to resume its original shape after it has been altered by any of the physiological actions of the eye. The elasticity of the vitreous tissue has been already adverted to (vol. ii. 1868, p. 378). Further evidence that it is possessed of this physical property might be multiplied. I will only mention one other example. Place a fragment of vitreous between two slips of glass, previously rendered opaque by a weak solution of nitrate of silver, to enable its action to be more readily observed. On pressing the glasses in contact the vitreous tissue is observed to expand, and on removing the pressure it instantly regains its former size. The hyaloid membrane is not extensible, though it bears a greater strain than might be at first supposed. The elasticity of the limiting membrane of the anterior hemisphere is a well-established fact.* The elastic stractures of the aqueous capsule of the eye contract upon the contained fluid, and give it the character of a solid sphere. In the healthy state of parts it is always full, offering in front a smooth surface for the perfect refraction of the rays of light, and behind for the close adaptation of the retina which is spread out upon it.

But not only is the aqueous capsule, in health, always full, but the fluid which it encloses subjects it to a distending force, against which it reacts in an equal degree. The distending force to which the anterior hemisphere is subjected is often illustrated in practice in cases of ulceration Bowman: Op. cit., p. 19.

The distending force, however, to which the aqueous capsule is subjected by the fluid which it encloses is confined within the capsule itself; outside the capsule the distending force ceases to exist. This may be illustrated by the following experiment:-In a dying person, or in a body immediately after death, when the heart is either failing in power or has ceased to beat, the only obvious physical difference in the eye in such a case and that of a person in the vigour of life is, that the choroid has partially emptied itself of blood, and the sclerotica has become soft from the want of support within. In such circumstances, if pressure be made on the eyeball with the two forefingers, the vitreous is felt as a hard globular body within the eye, apparently of its normal position and size. Now, if the vitreous communicated any distending force beyond the hyaloid membrane to the outer tunics of the globe, or if the latter reacted by an elastic force upon the vitreous body, the tension of the eyeball would not diminish in the ratio of the weakness of the heart's impulse, but the place of the receding current of blood would be taken, in the one case, by the distending vitreous, in the other by the contracting tunics. That the distending force of the fluids of the eye is borne entirely by the aqueous capsule and structures within it, is also deducible from the difference between the form of the eyeball in health and that which it assumes in some diseases. In the normal eye the aqueous capsule forms a sphere (of which the cornea constitutes a segment), the radius of which is somewhat less than that of the sclerotica, and which cuts the latter at its junction with the cornea. The cornea therefore is more convex than the sclerotica, and at the line of junction a slight depression exists, on account of the angle which the two structures form with each other. The sclerotica forms no part of the sphere, and therefore can sustain no part of the distending force of the fluids of the eye; for if it did, the cornea and sclerotica would be segments of a sphere having the same radius. But when the aqueous capsule becomes enlarged by a superabundance of fluid, such as occurs in glaucoma, the lesser sphere (the aqueous capsule) becomes enlarged, so that the distending force formerly borne by it comes to bear upon the sclerotica: in a word, the lesser sphere merges into that of the sclerotica, and, as a consequence, the cornea takes on the curve of the latter tunic, the depression which normally exists at the junction of the two structures becoming obliterated.

As the distending force in both hemispheres of the aqueous capsule is the same, pressure upon the cornea with the two forefingers elicits the hydrostatic pressure, and consequently the tension to which its entire circumference is subjected. Accordingly, the tension of the aqueous capsule may be ascertained by causing the person under examination to close the eyelids, on the upper of which the surgeon places his two forefingers, and presses upon the cornea as if he were examining for fluctuation. The resistance which the cornea gives to the pressure of the finger is an index of the

distending force to which both hemispheres of the aqueous capsule is subjected. The tension of the cornea in health should be first learned, and used as a standard, to which the exalted or diminished degrees of tension which it acquires in various diseases may be compared. The formulæ first adopted by Mr. Bowman for noting the tension of the sclerotica may be employed also for the cornea, but as these are well known to ophthalmic surgeons I need not refer to them here.

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(To be continued.)

OBSERVATIONS

ON THE

TREATMENT OF TROPICAL DISEASES.

BY J. T. GRAY, L.R.C.P. LOND., SURGEON IN THE PENINSULAR AND ORIENTAL COMPANY'S SERVICE. (Concluded from p. 600.)

hepatitis materially favour the access of muco-enteritis and subsequent ulceration;" and, in another place, that "individuals under the influence of mercury are very predisposed to dysentery." If such be the occasional evil results of mercurial treatment, it must surely be owing to a lurking belief in the mythical specific influence before alluded to that it is adopted at all in such cases.

I have especially referred to dysentery and hepatitis, but my own observations during a number of years, not only on these diseases, but on the treatment of disease generally in India, have impressed me strongly with the belief that the tendency of the treatment hitherto and even now too much adopted has been to increase the severity of many of them. Dr. Peet remarks that "the early symptoms of very serious attacks of dysentery are often to appearance of a very mild nature." That is true; but I maintain that the administration of ten or fifteen grains of calomel at the onset of a mild attack is the very way to make it a severe one. I am certain that half the quantity is enough to bring on, to create, an attack of dysentery in some individuals. It cannot be said that the treatment under consideration is only advised in certain typical examples of disease; it is prominently brought forward in most of the works on Indian diseases as generally applicable. It is still the custom, in systematic medical works, to commence with qualified recommendations of the use of bleeding, &c., in considering the treatment of such diseases as pneumonia and bronchitis. What was formerly important is still placed first, and ". precedent" is perhaps the most feasible explanation of the primary allusion to and recommendation of a mode of treatment formerly considered suitable to the majority of cases, but now, if at all, only applicable to a small minority; yet, in the recent and excellent work of Dr. Murchison on Diseases of the Liver, we are told that "acute congestion in tropical climates is often benefited by more active measures than would be justifiable in the forms of congestion which are more common in England." Further on he remarks, certainly most cautiously, that "when the disease sets in suddenly, and when the pulse is full and firm and the temperature high, a full bleeding from the arm, by diminishing the force of the heart and the total amount of blood, will sometimes appear to check the advance of the disease to suppuration." It is evident that the days of active measures are not yet numbered. I may remark here that Dr. Murchison maintains the now generally received opinion, that there is no evidence that mercury stimulates the liver to increased secretion, for if it did it would be injurious in cases of hepatic congestion, in which cases he avers it is of "unquestioned utility."

WITH such instructions and examples as these by the highest authority" on Indian diseases, can we wonder at the immense number of our troops in the East who are annually invalided home on account of " anæmia," "general debility," "tropical cachexia," &c. ?-affections which are often directly traceable to the "high hand." I trust I may be pardoned for expressing a hope that the young army surgeons arriving out in India, fresh from Netley, and well grounded in the principles of modern pathology and therapeutics, will have courage to think and act for themselves in accordance with these principles; though it must be confessed that some of the professors at this capital school appear to be rather too bloodthirsty in the practice they enjoin. Thus, Professor Aitken, in his well-known and admirable work, after stating, "as a general result, that bloodletting will not cut short the morbid process in acute hepatitis," remarks that "in the young and sthenic European it is generally necessary to take fifteen or twenty ounces [of blood], or till the skin becomes soft and relaxed, or the pain abates." Mercury, however, he considers "not only inefficient, but injurious." Again, on the subject of dysentery Dr. Aitken hardly ventures to have an opinion of his own, but believes that "the best general rules that we possess" are those recommended by Sir James M'Grigor, Sir Ranald Martin, and Professor Maclean. This is rather emAfter a few years' residence in India Europeans commonly barrassing to the student: for the first two gentlemen are become more or less asthenic, though now and then they strong advocates for "copious venesection," calomel, &c.; present a false appearance of strength, which is not indicawhilst Professor Maclean states that "the most judicious tive of a greater power of resisting the onslaught of acute and successful practitioners in India rarely bleed now, even disease. The natives of the country, it is generally acknowin the most sthenic forms of the disease, and confine the ledged, bear depletion badly; but a ruddy, robust, newly use of leeches within the narrowest limits." Calomel, too, arrived Englishman is a different being; he is plethoric, he maintains" has no specific action on the disease, and its forsooth, and must be bled, or have his " vascular turgidity" cholagogue effects can be attained by remedies which are reduced somehow. Indeed, the practical deduction to be not open to such objections as can be brought against mer- drawn from both the older and more recent writings on cury. Contrary to this, Sir Ranald Martin, writing in Indian diseases appears to be this: if a strong man is 1861, says that "amongst the surgeons of Bengal, blood-attacked by an acute disease in India, you must weaken letting, general and local, takes the lead, and has done so for many years, in the treatment of dysentery. It is the standard remedy." Even Dr. Morehead, in his "Researches" -by far the most satisfactory single book on Indian diseases,-appears to be haunted with an idea of the necessity of subduing "vascular turgescence" in dysentery and hepatitis by local and general bloodletting, though his opinion is so qualified that the cases to which they are applicable must be comparatively few in number. Dr. Peet follows Dr. Morehead very closely in every respect. They both advocate the use of a preliminary dose of ten or fifteen grains of calomel in the early stages of dysentery and hepatitis. The recommendation of this large dose appears all the more strange when we find that they consider themselves to be opponents of the mercurial treatment of these diseases. Dr. Morehead administers the calomel with a view "to increase the secretion of the liver and the mucous lining of the small intestines," and cautions against aggravating the existing inflammation of the large intestine by This is not the place to discuss, in extenso, the treatment its too frequent repetition. He also observes that "mer- of the acute diseases of India, but I may state in conclusion curial and other purgatives too frequently repeated into confirm, it may be, a doubtful mind in search of pre

him as much as possible to enable him to get over it; if a
weak man is attacked, you must strengthen him as much
as possible with the same object in view. A multitude of
quotations might be produced to prove that this deduction
is in accordance with the practice enjoined by the lights of
Indian practice; but, as in theology, doubtless also in
physic, how many men are better than their creeds!
I believe the number of "judicious and successful prac-
titioners" referred to by Professor Maclean is on the in-
crease in the East. Many of the articles in the Indian
Annals of Medical Science of modern date, and in other
Indian medical journals, indicate steps taken in the right.
direction; whilst the discussions which take place at the
medical societies of Bombay and other places show that,
though some minds may be of the retrogressive order-not
merely conservative, but with a tendency to revert to ex-
ploded views,-others, and I hope many, are adding to the
strength and stability of the "young physic" of the day.

cedent for negative rather than heroic practice--that during the last four years I have neither bled nor applied leeches in a single case of hepatitis or dysentery; nor have I given so much as a five-grain dose of calomel to any patient for any purpose, and I have every reason to be well satisfied with the results. On the other hand, the cases I have seen in which active measures were unsparingly carried out, have, for the most part, terminated unfavourably. The beneficial effect of a sea-voyage in many instances, I have little hesitation in saying, is due, in a considerable degree, to the negation of active treatment; and holding this opinion, I protest all the more strongly against the inconsiderate and too common practice of sending dying men for a sea-voyage as their "last chance." I have known patients carried on board the mail steamer in Bombay harbour in the last stages of dysentery and hepatic abscess, in the height of the monsoon, with the certain prospect of being subjected for eight or ten days to all the distresses and discomforts incidental to steaming against a gale of wind. To send such patients as I have described to sea, under the circumstances just mentioned, is really to throw away their last chance of recovery. Exceptional cases occur now and then, but the majority die before the voyage is half over. It is not to be expected that any benefit can be derived from a sea-voyage by almost moribund patients, and during the bad weather season it is downright cruelty to expose them to its miseries. If dysenteric patients were sent to sea early, or when not much depressed, even a monsoon voyage may prove beneficial, and patients in a still later stage of the disease may hope for benefit from a voyage in the fine season. When, however, utterly prostrate and helpless patients are carried on board during the south-west monsoon, a good result is most problematical. It should also be remembered that dysenteric patients on board ship are, from the nature of their disease, a source of discomfort and annoyance to those around them. This, of course, in a philanthropic point of view, is only a secondary matter, but, when a patient's chance of improvement is visionary, should not altogether be forgotten. Whilst agreeing with one of our medical classics that the worst air for a patient is that where his disease originated, I cannot but think that a practitioner will do more to prolong the life of such patients as those described by careful diet and good nursing, by perfect rest, and, in the case of dysentery, by the use of, perhaps, such remedies as bismuth and morphia, than by subjecting them to the commotion and excitement necessarily attendant upon undertaking a long sea-voyage. Bombay, 1869.

DIAGNOSIS OF HANGING.

BY ANDREW ALLISON, M.D.,

ONE OF THE HONORARY SURGEONS TO THE LLOYD DISPENSARY, BRIDLINGTON.

QUESTIONS of medical jurisprudence have not hitherto occupied a very prominent place in our periodical literature. The practical interest taken in medico-legal subjects is limited to a few experts, and the general practitioner is seldom employed in the higher branches of forensic medicine. Gentlemen who have been educated in Scotland often neglect to cultivate a competent knowledge of chemistry and physiology, in their application to the detection of crime. Caledonian students affect to believe that their altitude in scientific attainments will warrant a degree of indifference to the less attractive branches of an encumbered education. Such persons, in after life, generally exhibit a notable ignorance of the able teachings of the northern schools.

In Scotland, coroners' inquests are unknown; but in England they are of daily occurrence, and medical practitioners are liable to be summoned to give evidence as often as scientific difficulties are involved in such investigations. When the professional referee manifests any degree of ignorance or oscillation in his testimony, the jury invariably draw conclusions adverse to the professional reputation of the witness, and the facts which the inquiry ought to establish are sometimes obscured by his unsound deductions.

Before proceeding to comment upon the fallacy of marks upon the throat as a diagnostic sign of hanging, I shall take the liberty of reasoning somewhat analogically on to the question which I am desirous of ventilating. In morbid states of the nervous system, expressed by neuralgic pains, the tolerance of anodynes is proportioned to the pathological lesion. For example, in tic-doloureux, a large dose of opium may be administered without even giving rise to a sense of drowsiness; whereas, in the physiological state, this dose would in all probability produce decided symptoms of narcotism. Thus, by graduating the dose to the urgency of the disease, the excess, if any, is alone liable to detection. This fact serves to show the characteristic impressions produced in opposite states of the organism. By gauging the quantity of calomel capable of being converted into the bichloride of mercury in the stomach, the therapeutic properties of the alterative are obtained, and that only which is in excess, and disproportioned to the action of the gastric chlorides, can be detected as a subchloride in the intestines. In like manner, by regulating the amount of strychnine taken into the stomach for killing purposes only, all traces of the alkaloid disappear from the body at death; and that portion, if any, which remains unabsorbed can alone be detected by the analyst. In hanging or strangulation, provided the constricting force applied be moderate, and not continued beyond the extinction of life; no furrow of the cord is usually apparent upon the neck; for it must be remembered that the mark is a post-mortem production, and not invariably present as a diagnostic sign of hanging, unless the drop be considerable, or the suspension continued beyond the actual death of the individual. I was recently summoned to a woman who had suspended herself by means of a piece of sheep-netband, but who was cut down by her husband before life was extinct. No mark of the ligature was ever visible; and had she died, and the cord been secreted, the cause of death might have remained a mystery for want of the alleged diagnostic mark upon the neck, and the attention of the coroner's jury probably directed to some unintelligible spasm of the heart as the supposed cause of the visitation. Had this woman been suspended for a longer time, the post-mortem mark would then, no doubt, have been visible. On another occasion, I was called to a man who hanged himself by means of a ploughstring. He was absent from his family only six minutes, and when he was cut down no print of the cord was afterwards found upon the neck. Indeed, in the case of this drunkard, had a homicidal act taken place by hanging, and the real cause of death been concealed, the alleged diagnostic cord mark could have thrown no light on the manner of his death. Some years ago, I saw a weighty farmer, who had been suspended for a few minutes. At the inquest no perceptible ecchymosis, or mark of the halter, was then observable. A person may be murdered by hanging or strangulation, and the absence of a mark only indicate that the ligature had been removed as soon as life became extinct, or before the post-mortem indentation had been developed. As in the cases of opium, calomel, and strychnine, already alluded to, the excess of those drugs only manifests their detectible presence in the system; so the excess of hanging, beyond that which causes death, alone gives rise to the characteristic secondary impression of the cord. The presence of a groove encircling the neck only proves that it was originated after death, and not that hanging was the primary cause of the calamity. A few years ago, mechanical force was applied to a gentleman's and as the signs of the outrage were but slightly displayed throat at Scarborough, which he survived for several days; externally, several medical gentlemen of the borough imagined the original cause of death to be apoplexy, for getting that the living tissue will resist impressions which the post-mortem condition will readily yield to. The judge who tried the culprits in this case was of opinion that death was primarily caused by strangulation.

The conclusions which I draw from a full consideration of such transactions are- - that death, in the case either of strangling or hanging, is so sudden, that the production of a mark of the cord, in any of its peculiar forms, takes place after death. Indeed, the track of the cord is a purely cadaveric phenomenon, and its value exceedingly questionable as a diagnostic proof either of suicidal or homicidal hanging. A body cut down as soon as life has become extinct will hardly exhibit any external signs of violence;

whilst a dead subject, suspended for five minutes, will after-morphia pill at night. On examination to-day the edge of wards manifest mummification of the mark of the cord, the liver is to be felt a quarter of an inch above the umbithe result of evaporation from the body, and must, there- licus, and extends with the usual curve to the right and fore, be a post-mortem production. In diagnosing death left; the veins on the surface of the abdomen are much disfrom hanging or strangulation, where no marks are visible, tended; pain and tenderness all over the abdomen; fluctuathe medical jurist must take into consideration the sur- tion at a point about two inches above and to the right of rounding circumstances of the whole case, and then pro- umbilicus. ceed to satisfy himself, pathologically, whether apoplexy, asphyxia, or neuro-paralysis, were conditions immediately concerned in arresting life. Under such an ordeal the medical inquisitor will be able to deduce conclusions satisfactory to a jury, and creditable to his own forensic sagacity. Bridlington, May, 1869.

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A CASE OF HYDATID CYST OF THE LIVER; SUPPURATION; EVACUATION OF PUS AND HYDATIDS; EXHAUSTION; DEATH.

(Under the care of Dr. SIEVEKING.)

WE were present at the autopsy of this case, which seemed of sufficient interest to deserve recording; and Mr. J. R. Walker has been good enough to give us some notes, which are appended.

Arthur D, aged seventeen, admitted February 12th, 1869, suffering from pleurisy with effusion. On admission, the following history was obtained:-Family pretty healthy. The patient has hitherto enjoyed good health. In November last he felt a pain in the right side and stomach, which lasted about three days. About a month ago he felt a pain again in his right side, which he compared to a lump being there. This pain was worse when he lay down. He soon experienced difficulty in breathing in going up stairs, and was obliged to leave off work.

On examination, the right side appeared the larger, but on measurement no difference was detected; the circumference just below the nipples was 30 inches. Breathing good over left front, also over the upper half of right side, below which there is absolute silence and dulness. Both sides seem to move equally in respiration. Resonance over left front less than over right front; vocal resonance much better over left than right. Heart-sounds normal. When he lies on his face the right posterior lower half is not nearly so resonant as the corresponding part on the left; still it is not so dull as on the front. Pulse 102, of medium force. Tongue moist and coated. Urine dark-coloured, not acid; specific gravity 1030; and contains a large deposit of phosphates, but no albumen. Ordered iodide of potash, five grains, and bicarbonate of potash, five grains, three times a day; broth, beef-tea, and milk.

Feb. 13th.-Absolute dulness below fifth rib on right

side.

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23rd.-Great swelling in right hypochondrium; fluctuation more distinct; tumour evidently pointing where fluctuation was first felt. Urine of a yellow-reddish colour, contains bile, acid, specific gravity 1030.

27th. The liver was punctured by a small hypodermic syringe, and pus drawn off. A larger trocar was then inserted, and about eight ounces of fluid, with small gelatinous masses, was drawn off. The canula was left in and plugged. Brandy, six ounces daily.

28th. The syringe was again inserted, and two or three ounces of a similar fluid evacuated. Has had a rather restless night; pulse 128, small and wiry. Patient is becoming very emaciated; countenance anxious and flushed; pain in the abdomen much relieved since operation; takes his food tolerably well. Fish diet, also six ounces of port wine and six ounces of brandy daily.

30th. An incision was made, and about ten ounces of offensive pus, with a large quantity of gelatinous masses containing hydatids, evacuated. Two grains of quinine mixture to be taken thrice a day.

31st. This morning fifty ounces of pus, extremely offensive, were discharged (more remaining behind). The liver was thus reduced in size by about two inches, and tension removed. No tenderness, except at the edge of the wound. Pulse 104. No sleep last night.

April 1st.-Slept well, owing to an opium draught, which was substituted for the morphia pill. Pulse 112. Eight ounces of fluid evacuated.

2nd. Sleepless night; pulse 127; six ounces of fluid evacuated.

3rd. No sleep; pulse 140; four ounces of fluid discharged. Stimulants increased.

4th. Sleepless night; pulse 180; cannot take his food so well; twenty ounces of fluid evacuated.

5th.-Passed a better night; pulse 140; eight ounces of fluid evacuated; has a blush of redness to the right of the incision; carbolic acid (1 to 100) injected without pain; bowels relaxed last two days. Stimulants ad libitum.

6th.-Pulse 180, smaller; cannot take his food at all; ten ounces of discharge, which is distinctly coloured with bile. 7th.-Pulse scarcely perceptible, 180; breathing laboured. Died at 11.55 P.M.

At the post-mortem examination, the body was found to be much emaciated, the outline of the liver being clearly visible. The liver itself occupied nearly the whole front of the abdomen, and encroached on the thorax, especially on the right side. It was generally adherent to the front abdominal wall (the spot of puncture being firmly adherent). Left lobe very much enlarged in length and width, but very thin, and covering the stomach, which was pushed to the left side. Right lobe almost entirely converted into a cyst or abscess, the walls of which were composed of thin discoloured liver tissue, not thicker than from one-eighth to one-fourth of an inch-except below, where there was unaltered liver tissue. The whole upper surface of the right lobe was firmly adherent to the diaphragm; below, to kidney and abdominal walls, where the cyst burst while detaching it, whereby several pints of fluid escaped, containing pus, with globules of lymph and gelatinous cysts. Both lungs were congested, and adherent to pleural walls by recent adhesions, with effusion in pleural cavities. Other organs healthy.

GREAT NORTHERN HOSPITAL.

CASE OF CONCUSSION OF BRAIN, FOLLOWED BY SYMPTOMS OF IRRITATION AND A SUCCESSION OF FITS, CONTINUING AT SHORT INTERVALS FOR TEN DAYS; QUESTION OF TREPHINING; TREATMENT BY ANTIMONY; RECOVERY.

(Under the care of Mr. W. ADAMS.) THE following case, for the notes of which we are indebted to Mr. P. D. Hopgood, is interesting in connexion with the question of trephining, which so often arises under

like circumstances, and about which there is still much difference of opinion amongst surgeons.

This man was seen by Mr. Hopgood in December, 1868, and he continued in good health, and able to follow his occupation; but had had three or four fits, not, however, of a severe form. He suffered from headache after stooping, or if he took more than one glass of ale daily. He had never been subject to fits before the accident.

Clinical Records

F. P, aged twenty-three, a healthy and very temperate man, was brought to the hospital, in a partially unconscious state, on Feb. 4th, 1868, having fallen from the top of a high cart, striking his head against the pavement. He was completely stunned by the fall; but in a few minutes spoke to those around, wishing to remain quiet. A few minutes after the accident he was taken in a chair into a house, and left for a while. During the interval he walked by himself up stairs, undressed, and went to bed,-where he was found when the attendants went to look after him. About an hour after the accident he vomited his dinner, mixed with some blood. At this time he became unconscious, but was very restless, curling himself up in bed, and pulling the clothes over his head. Afterwards he became somewhat sensible, and was very obstinate in being dressed EXTENSIVE PERFORATION OF THE STOMACH, ATTENDED BY previous to being taken to the hospital.

The patient was brought in a cab to the hospital at 6.30 P.M. Directly he was taken into the surgery he began to vomit blood in small quantities, mixed with food and fluid from the stomach. The surface of the body was cold, with pulse 60, feeble, and he persisted in curling himself up, and pulling the blanket he was wrapped in over his head. The pupils were contracted, and sensible to light. On examining the head, no wound was found; but there was a distinct depression, about the size of a shilling, on the posterior part of the right parietal bone. He was somewhat conscious, and his face rather flushed. Ordered beeftea and milk, ice to the head, and hot bottles to the feet. Reaction took place in a few hours, the body becoming warm, and the pulse rising considerably; breathing quiet. Late same evening: Pulse 80, feeble; breathing quiet; seems inclined to sleep.

Feb. 5th. No more vomiting. Got out of bed to pass water. Complains of great pain in the head. Ordered croton oil, one minim, immediately; tartrate-of-antimony wine, twenty minims, every four hours.

6th.-No sickness. Pain continues. Bowels open freely. Surface of body warm.

7th.-Has had several fits during the day; left side convulsed. Passes motions in bed. Pulse 96, feeble. Fits continue. Catheter passed twice daily. Ten leeches applied to temples. Pulse 100. Right pupil dilated.

8th. Pulse 84. Breathing inclined to be stertorous. Left arm paralysed. Pupils contract with stimulus of light. Has been taking tartrate-of-antimony wine, twenty minims, every four hours. Skin warm and perspiring. Violent convulsions every few minutes. (In the fits, the eyes are turned up and to the left; twitchings of face and whole of left side.) There was a consultation with Mr. Gay to consider the operation of trephining. Mr. Adams thought the symptoms of cerebral irritation probably depended upon some spicula of depressed bone, but as it was difficult to define the exact spot at which the trephine should be applied, it was decided to wait for further symptoms. 9th.-Pulse 96, very feeble. Pupils sensitive to light. Breathing quiet.

10th.-Pupils dilate thoroughly with atropine. Pulse 64. Fits continue every few minutes; conscious between them. 11th.-Pulse 96. He is unconscious. Fits continue. 12th. Fits continue very frequent. Pulse 100. Conscious between fits. Refuses nourishment; does not complain of pain.

13th.-Pulse 120. Fits very frequent. Depression in parietal bone plainly felt. Unconscious between fits. Continues the tartrate-of-antimony wine every four hours. 14th.-Eight fits during the day. Pulse 120.

15th.-Pulse 100; conscious; only one fit, in which the whole body was convulsed.

16th.-Six fits during the night; passes urine; pulse 96; much better; quite conscious.

17th.-Left arm paralysed; still continues tartrate-ofantimony wine; sleeps much.

18th.-No fit; talks indistinctly; sleeps a good deal. 19th. Very comfortable.

21st.-Improving; no fit.

25th.-Complains of being hungry.

THE

PARIS

OF

HOSPITALS.

HÔPITAL LARI BOISIÈRE.

PERITONITIS, WITHOUT ANY LOCALISED SYMPTOMS
DURING LIFE.

(Under the care of Dr. MILLARD.)

THE patient was a man of sixty-five years of age, and had led a tolerably comfortable life. On entering the hospital, on February 5th, there was general soft oedema, which extended to the face. The urine was normal, and the heart healthy. The patient had never had hæmorrhage. From what he said it was inferred that the disease had made its appearance four months previously: there was then a swelling of the legs, accompanied by general weakness, and this swelling had disappeared and returned at different intervals.

On examining the surface of the body, a large pemphigus bulla was discovered on the right leg, whilst the left showed a large, sore patch, probably due to pemphigus.

Feb. 20th.-For some days the patient has lost flesh, and has had excessive diarrhoea. With the increase of diarrhoea, the oedema has gradually disappeared, and the change thus produced adds to the emaciated aspect of the patient. The urine has been repeatedly examined, and no traces of albumen had been discovered.

21st. The diarrhoea disappeared this morning, and returned in the evening. The patient passed water without knowing it.

24th.-Patient was in a moribund condition, the face being extremely emaciated. Death occurred during the day without being attended by any phenomenon worthy of being noted.

Post-mortem examination.-Abdomen: General peritonitis, with a great quantity of pus, and soft false membranes. Liver connected with the stomach by soft false membranes, which easily gave way as the liver was detached, and disclosed a perforated ulcer of the stomach, as large as a halffranc silver piece. On separating the stomach from the transverse colon, another perforated ulcer was discovered, of the size of a five-franc silver piece. No effusion of intestinal matter in the peritoneum. The liver and kidneys were in a somewhat fatty condition. The heart showed no signs of disease, except some milky patches on its surface. There was an emphysematous condition of the lungs. Thick false membranes covered the pleura.

HÔPITAL NECKER.

CÆSAREAN OPERATION POST MORTEM; BIRTH OF
A LIVE CHILD.

(Under the care of M. GUYON.)

THE patient, on being admitted into the hospital, was in a state of profound apathy, and could scarcely give any information touching her condition. As far as could be gathered from her random answers, it appeared that she first fell ill about ten days before. On being asked where she felt pain, she pointed to the stomach. She had scarcely any fever, very slight cough, abundant diarrhoea, no typhoid maculæ on the abdomen, and a furred tongue without sordes.

March 5th.-Takes food well; improving fast; remembers Since the beginning of her pregnancy-which was approach

nothing about the accident.

17th.-No bad symptom.

April 30th.-Discharged well.

ing its end at the time of admission-she had had several fits of convulsions. She had never had any attacks before pregnancy. During the fifteen days she remained in the wards

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